Persistent sex disparities in clinical outcomes with percutaneous coronary intervention: Insights from 6.6 million PCI precedures in the United States

Background Prior studies have reported inconsistencies in the baseline risk profile, comorbidity burden and their association with clinical outcomes in women compared to men. More importantly, there is limited data around the sex differences and how these have changed over time in contemporary percutaneous coronary intervention (PCI) practice. Methods and results We used the Nationwide Inpatient Sample to identify all PCI procedures based on ICD-9 procedure codes in the United States between 2004–2014 in adult patients. Descriptive statistics were used to describe sex-based differences in baseline characteristics and comorbidity burden of patients. Multivariable logistic regressions were used to investigate the association between these differences and in-hospital mortality, complications, length of stay and total hospital charges. Among 6,601,526 patients, 66% were men and 33% were women. Women were more likely to be admitted with diagnosis of NSTEMI (non-ST elevation acute myocardial infarction), were on average 5 years older (median age 68 compared to 63) and had higher burden of comorbidity defined by Charlson score ≥3. Women also had higher in-hospital crude mortality (2.0% vs 1.4%) and any complications compared to men (11.1% vs 7.0%). These trends persisted in our adjusted analyses where women had a significant increase in the odds of in-hospital mortality men (OR 1.20 (95% CI 1.16,1.23) and major bleeding (OR 1.81 (95% CI 1.77,1.86). Conclusion In this national unselected contemporary PCI cohort, there are significant sex-based differences in presentation, baseline characteristics and comorbidity burden. These differences do not fully account for the higher in-hospital mortality and procedural complications observed in women

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Call to action for acute myocardial infarction in women: International multi-disciplinary practical roadmap

\ua9 2024 The Author(s). Published by Oxford University Press on behalf of the European Society of Cardiology.Cardiovascular diseases are the leading cause of death among women, and the incidence among younger women has shown the greatest increase over the last decades, in particular for acute myocardial infarction (AMI). Moreover, the prognosis of women post-AMI is poor when compared with men of similar ages. Since the 1990s, an abundant literature has highlighted the existing differences between sexes with regard to presentation, burden, and impact of traditional risk factors and of risk factors pertaining predominantly to women, the perception of risk by women and men, and the pathophysiological causations, their treatment, and prognosis. These data that have been accumulated over recent years highlight several targets for improvement. The objective of this collaborative work is to define the actions required to reverse the growing incidence of AMI in women and improve the patient pathway and care, as well as the prognosis. We aim to provide practical toolkits for different health professionals involved in the care of women, so that each step, from cardiovascular risk assessment to symptom recognition, to the AMI pathway and rehabilitation, thus facilitating that from prevention to intervention of AMI, can be optimized

Marital status and risk of cardiovascular diseases: A systematic review and meta-analysis

Background The influence of marital status on the incidence of cardiovascular disease (CVD) and prognosis after CVD is inconclusive. We systematically reviewed the literature to determine how marital status influences CVD and prognosis after CVD. Methods A search of MEDLINE and Embase in January 2018 without language restriction was performed to identify studies that evaluated the association between marital status and risk of CVD. Search terms related to both marital status and CVD were used and included studies had to be prospective in design. The outcomes of interest were CVD, coronary heart disease (CHD) or stroke incidence and mortality. We performed random effects meta-analysis stratified by the types of population by calculating odds ratios (OR) and 95% confidence intervals (95% CI). Results Our analysis included 34 studies with more than two million participants. Compared with married participants, being unmarried (never married, divorced or widowed) was associated with increased odds of CVD (OR 1.42; 95% CI 1.00 to 2.01), CHD (OR 1.16,95% CI 1.04 to 1.28), CHD death (OR 1.43,95% CI 1.28 to 1.60) and stroke death (OR 1.55,95% 1.16 to 2.08). Being divorced was associated with increased odds of CHD (P<0.001) for both men and women while widowers were more likely to develop a stroke (P<0.001). Single men and women with myocardial infarction had increased mortality (OR 1.42, 95% CI 1.14 to 1.76) compared with married participants. Conclusions Marital status appears to influence CVD and prognosis after CVD. These findings may suggest that marital status should be considered in the risk assessment for CVD and outcomes of CVD based on marital status merits further investigation

Effect of Gender On Unplanned Readmissions After Percutaneous Coronary Intervention (From The Nationwide Readmissions Database)

Women who undergo percutaneous coronary intervention (PCI) are at higher risk of adverse outcomes compared with men, but it is unknown whether gender affects early unplanned rehospitalization. We analyzed 832,753 patients who underwent PCI from 2013 to 2014 in the Nationwide Readmissions Database. We compared gender differences in incidences, predictors, causes, and cost of unplanned 30-day readmissions and examined the effect of co-morbidity. A total of 832,753 men and women who survived the index PCI and were not admitted for a planned readmission were included in the analysis. Overall, 9.4% of patients had an unplanned readmission within 30 days. Thirty-day readmission rates were higher in women compared with men (11.5% vs 8.4%, p <0.001) even after multivariate adjustment (odds ratio 1.19, 95% confidence interval 1.16 to 1.22, p <0.001), although women had significantly lower costs associated with the readmission ($11,927 vs$12,758, p <0.001). The cause of readmission for women and men were similar and the majority of the readmissions were due to noncardiac causes (58% vs 55%), the most common of which were nonspecific chest pain, gastrointestinal disease, and infections. In contrast, for cardiac readmissions, women are more likely to be readmitted for heart failure (29.64% vs 22.34%), whereas men are more likely to be readmitted for coronary artery disease, including angina (33.47% vs 28.54%). In conclusion, gender disparities exist in rates of unplanned rehospitalization after PCI, where more than 1 in 10 women who undergo PCI are readmitted within 30 days. Gender differences were not observed for causes of noncardiac readmissions, whereas important differences were observed for cardiovascular causes

Antithrombotic drugs for acute coronary syndromes in women:sex-adjusted treatment and female representation in randomised clinical trials. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the ESC Working Group on Thrombosis

Thrombotic and bleeding risks differ between sexes, partly in relation to distinct biology and hormonal status, but also due to differences in age, comorbidities, and body size at presentation. Women experience frequent fluctuations of prothrombotic and bleeding status related to menstrual cycle, use of oral contraceptives, hormone replacement therapy, or menopause. Although clinical studies tend to underrepresent women, available data consistently support sex-specific differences in the baseline thrombotic and haemorrhagic risks. Compared with men, women feature an increased risk of in-hospital bleeding related to invasive procedures, as well as long-term out-of-hospital bleeding events. In addition, the inappropriate dosing of antithrombotic drugs, which is not adapted to body weight or renal function, is more frequently associated with an increased risk of bleeding in women compared to men. While acute coronary syndrome (ACS) studies support similar antithrombotic drug efficacy, irrespective of sex, women may receive delayed treatment due to bias in their referral, diagnosis, and invasive treatment decisions. The current clinical consensus statement highlights the need for an increased awareness of sex-specific risks and biases in ACS management, with a focus on sex-specific bleeding mitigation strategies, antithrombotic management in special conditions (e.g., myocardial infarction with non-obstructive coronary arteries), and barriers to female representation in cardiovascular trials. This manuscript aims to provide expert opinion, based on the best available evidence, and consensus statements on optimising antithrombotic therapy according to sex, which is critical to improve sex-based disparities in outcome

Rationale and design of the CONFIRM2 (Quantitative COroNary CT Angiography Evaluation For Evaluation of Clinical Outcomes: An InteRnational, Multicenter Registry) study.

BACKGROUND In the last 15 years, large registries and several randomized clinical trials have demonstrated the diagnostic and prognostic value of coronary computed tomography angiography (CCTA). Advances in CT scanner technology and developments of analytic tools now enable accurate quantification of coronary artery disease (CAD), including total coronary plaque volume (TPV) and low attenuation plaque volume (LAP). The primary aim of CONFIRM2, (Quantitative COroNary CT Angiography Evaluation For Evaluation of Clinical Outcomes: An InteRnational, Multicenter Registry) is to perform comprehensive quantification of CCTA findings, including coronary, non-coronary cardiac, non-cardiac vascular, non-cardiac findings, and relate them to clinical variables and cardiovascular clinical outcomes. DESIGN CONFIRM2 is a multicenter, international observational cohort study designed to evaluate multidimensional associations between quantitative phenotype of cardiovascular disease and future adverse clinical outcomes in subjects undergoing clinically indicated CCTA. The targeted population is heterogenous and includes patients undergoing CCTA for atherosclerotic evaluation, valvular heart disease, congenital heart disease or pre-procedural evaluation. Automated software will be utilized for quantification of coronary plaque, stenosis, vascular morphology and cardiac structures for rapid and reproducible tissue characterization. Up to 30,000 patients will be included from up to 50 international multi-continental clinical CCTA sites and followed for 3-4 years. SUMMARY CONFIRM2 is one of the largest CCTA studies to establish the clinical value of a multiparametric approach to quantify the phenotype of cardiovascular disease by CCTA using automated imaging solutions

AI-quantitative CT coronary plaque features associate with a higher relative risk in women: CONFIRM2-Registry

Background: Coronary plaque features are imaging biomarkers of cardiovascular risk, but less is known about sex-specific patterns in their prognostic value. This study aimed to define sex differences in the coronary atherosclerotic phenotypes assessed by artificial intelligence-based quantitative coronary computed tomography (AI-QCT) and the associated risk of major adverse cardiovascular events (MACE). Methods: Global multicenter registry (CONFIRM2) including symptomatic patients with suspicion of CAD referred for coronary CTA. AI-QCT analyzed 16 CAD features. Primary endpoint was MACE defined as death, myocardial infarction, late revascularization, cerebrovascular events, unstable angina and congestive heart failure. Results: Among 3551 patients (mean age 59±12 years, 49.5% women), MACE occurred in 3.2% of women and 6.1% of men during an average follow-up of 4.8±2.2 years. The AI-QCT features total plaque volume (TPV), noncalcified plaque (NCP), calcified plaque (CP) and percentage atheroma volume (PAV) were significantly higher in men (p&lt;0.001), and high-risk plaque (HRP) was more prevalent (9.2% vs 2.5%, p&lt;0.0001). Independent of age and cardiovascular risk factors, the AI-QCT derived features of TPV, NCP, CP, and PAV conferred a higher relative risk of MACE in women than men. For every 50mm3 increase in TPV, relative risk increased by 17.7% (95% CI 1.12-1.24) in women vs 5.3% (95% CI 1.03-1.07) in men (p-interaction&lt;0.001), for NCP relative risk increased by 27.1% (95% CI 1.17-1.38) vs 11.6% (95% CI 1.08-1.15) (p-interaction = 0.0015), and for CP, by 22.9% (95% CI 1.14-1.33) vs 5.4% (95% CI 1.01-1.10) (p-interaction = 0.0012), respectively. Similarly, for PAV the risk was higher in women. The findings remained unchanged when restricted to a secondary composite endpoint (death and myocardial infarction). Conclusions: The AI-QCT plaque features TPV, NCP, CP and PAV conferred a higher relative MACE risk in women and may prompt more aggressive anti-atherosclerotic therapy and reinforced preventive interventions