DOI:

The gender paradox

Patrizia Presbitero, MD

Coronary revascularisation in women with either CABG or PTCA has been burdened with higher mortality and complications rates. Due to improvements in operative surgical techniques and PCI materials, a general increase in success rates for both techniques has occurred over the past decade1-3. However, today we lack trials comparing the two techniques in women and so the work of S. Vaina – who looked at this problem in the ART I and ART II trials, comparing stenting with surgery in multivessel coronary disease – is important.4

First of all, the study confirmed that females who need coronary revascularisation are sicker than men because of older age and comorbid conditions, particularly diabetes and hypertension. Unlike in other trials5, the anatomical features (number of diseased vessels, length of diseased segments) were not different between men and women.

Secondly, it is of note that there was an observed zero periprocedural mortality in either women or men in the PCI with DES arm in ART II, in comparison with a 4,1% in-hospital mortality of women in the CABG arm of the ART I study. Even if this represents an older trial, mortality after CABG in ART I was only 0,4% in men, confirming the higher mortality in women undergoing cardiac surgery in comparison with men observed in several previous studies6. Possible explanations range from small vessel size, to small body index, to worse general clinical condition in women. On the contrary, the increasing success of PCI in the last few years, especially in the DES era, have eroded the differences in results between men and women, making PTCA in women a safe procedure. We have to take into account, however, that in several large published trials7 the complication rate of PCI was higher in women due to a higher risk of vessel dissection, or the extension and the amount of calcifications in an older population, to small vessel size and marked vessel tortuosity.

Thirdly, the MACE-free survival at 1 and 3 years after PCI with DES in ART II in women was similar to female patients treated with CABG in ART I. The hard endpoints of death, myocardial infarction and cerebrovascular accident were less in PCI patients, demonstrating – at least at midterm follow-up – the safety of PCI in multivessel coronary disease in women. Between 1 and 3 years however, a catch-up phenomenon was observed in the rate of repeat PCI, with a trend to more frequent subsequent revascularisation, even with DES. This phenomenon has been reported in many studies, due to either in-stent restenosis or more likely to progression of the atherosclerotic disease, particularly in diabetic patients. This could affect long term outcome, especially in women, with a high prevalence of diabetes.

The restenosis rate, however, was similar or even lower in women than men after either bare-metal or drug eluting stents. This “paradox” was reported previously by other authors8,9 who showed a lower risk of restenosis in spite of the presence of adverse clinical (diabetes) or anatomic (small vessels, long lesions) features for restenosis. The improvement in PCI techniques, as pointed out by these authors, is surely one of the reasons to account for improved results. Other still unproven mechanisms may be linked to differences in plaque composition: younger plaques with thinner fibrous caps may be more prevalent in women10.

Fourthly, sirolimus-eluting stent implantation may lead to significant improvement of PCI results in both sexes, but possibly more so in women (re-PCI at 3 years in ARTS II of 8.5% in women as compared to 13.5% in men, see Tables 6 and 8 in Vaina et al). Women benefit as much as men in reducing late revascularisations with SES as compared to bare-metal stents, even if they start off with worse clinical characteristics. On the contrary, an analysis of the TAXUS IV study in women, showed similar outcome among the sexes, but women benefit less than men from the use of DES. In this large randomised prospective trial, the female sex was not an independent predictor of outcome11.

To conclude, we need more data with longer term follow-up to draw any definitive conclusions about the best revascularisation strategy in women. At present, given a generally higher surgical morbidity with CABG in women, and the encouraging improvement in results with DES PCI, an initial percutaneous approach may be strongly considered in an anatomically suitable subset of female patients.


References

Volume 4 Number 4
Jan 20, 2009
Volume 4 Number 4
View full issue


Key metrics

Suggested by Cory

Editorial

10.4244/EIJ-E-25-00003 Feb 17, 2025
Do we need to be fully complete in multivessel acute myocardial infarction?
Smits P and Paradies V
free

Editorial

10.4244/EIJ-E-25-00002 Feb 17, 2025
The future of complete revascularisation: prioritising imaging-guided non-culprit lesion assessment
Diletti R and Elscot J
free

Research Correspondence

10.4244/EIJ-D-24-00734 Feb 17, 2025
Angiography-based radial wall strain in carotid plaques and its association with plaque vulnerability
Suo S et al

Original Research

10.4244/EIJ-D-24-00720 Feb 17, 2025
Functional or anatomical assessment of non-culprit lesions in acute myocardial infarction
Xu X et al
Trending articles
200.45

State-of-the-Art

10.4244/EIJ-D-21-00089 Jun 11, 2021
Intracoronary optical coherence tomography: state of the art and future directions
Ali ZA et al
free
154.43

State-of-the-Art

10.4244/EIJ-D-22-00776 Apr 3, 2023
Computed tomographic angiography in coronary artery disease
Serruys PW et al
free
92.95

State-of-the-Art Review

10.4244/EIJ-D-20-01296 Aug 27, 2021
Management of cardiogenic shock
Thiele H et al
free
47.4

State-of-the-Art

10.4244/EIJ-D-24-00386 Feb 3, 2025
Mechanical circulatory support for complex, high-risk percutaneous coronary intervention
Ferro E et al
free
43.65

Clinical research

10.4244/EIJ-D-23-00590 Dec 4, 2023
Prognostic impact of cardiac damage staging classification in each aortic stenosis subtype undergoing TAVI
Nakase M et al
free
36.5

State-of-the-Art

10.4244/EIJ-D-23-00448 Jan 15, 2024
Coronary spasm and vasomotor dysfunction as a cause of MINOCA
Yaker ZS et al
free
34.75

State-of-the-Art

10.4244/EIJ-D-23-00606 Jan 1, 2024
Targeting inflammation in atherosclerosis: overview, strategy and directions
Waksman R et al
free
X

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

EuroPCR EAPCI
PCR ESC
Impact factor: 7.6
2023 Journal Citation Reports®
Science Edition (Clarivate Analytics, 2024)
Online ISSN 1969-6213 - Print ISSN 1774-024X
© 2005-2025 Europa Group - All rights reserved