stent or surgery: what is best for a woman ? dr r h stables cardiothoracic centre liverpool uk
TRANSCRIPT
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Stent or Surgery:
What is Best for a Woman ?
Dr R H Stables
Cardiothoracic Centre Liverpool
UK
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Conflict of Interest
• I am (or at one time was) a man
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Understanding the Problem
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Cardiovascular Disease - The Facts
• 3 million UK residents have coronary disease
• Effective treatment and prevention strategies exist
• Kills 3 times as many women as cancer
• Causes one quarter of all early death
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Medical Advice: Not Consistently Helpful
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Background: Coronary Artery Disease in Women
• Initial presentation at an older age
• Natural history of disease process
• Systematic failure of early recognition
• More frequent acute event presentations
• More advanced patterns of disease
• Risk factor profiles - Increased co-morbidity
• Smaller body surface area
• Coronary vessels of smaller calibre
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Background: Coronary Artery Disease in Women
• Female patients under-represented in clinical trials
• Major cardiovascular drug classes
• Revascularisation
• Compounds problems with generalisation of trials
• Undermines the evidence base
• May lead to use of inappropriate treatments
• Increases reliance on observational studies
• Compromised by bias (recognised or covert)
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Coronary Artery Bypass Surgery
• Surgical results - improved over the last 20 years
• Majority of additional risk explained by
• Age and more advanced disease patterns
• Conventional risk factors and co-morbidity
• Excess, unexplained gender risk persists
• EUROSCORE surgical risk calculations
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EUROSCORE Surgical Risk Calculator
• 60 Years Stable angina Good LV No Risks
• Logistic Mortality: Male 0.94% Female 1.3%
• 60 Years Unstable angina Poor LV No Risks
• Logistic Mortality: Male 4.77% Female 6.51%
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CABG in Female Patients
• Smaller coronary arteries - technical difficulties
• Also affects choice of graft conduit
• Less IMA pedicle grafting
• Smaller radial arteries
• Younger patients may be particularly affected
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CABG in the Younger Female Patient
Circulation 2002;105:1176-1181
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Greater Mortality Difference in Younger Patients
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CABG in Female Patients
• Smaller coronary arteries - technical difficulties
• Also affects choice of graft conduit
• Less IMA pedicle grafting
• Smaller radial arteries
• Younger patients may be particularly affected
• Higher rates of ‘surgical morbidity’
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Surgical Morbidity in Female Patients
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PCI in the Female Patient
• No additional mortality - beyond conventional risk
• May be associated with an increased MACCE rate
• NWQIP risk model for in-hospital MACCE
• Odds ratio 1.58 (1.08 - 2.33, p = 0.019)
Heart 2006; 92: 658-63Heart 2006; 92: 658-63
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PCI in the Female Patient
• Observational studies suggest ↓ BMS restenosis
• Seems odd - smaller vessels, more diabetes
• ? Protective effect of oestrogen
• Selection bias
• At time of revascularisation
• Quality of follow-up
• Willingness to re-intervene
• DES efficacy confirmed in female patients
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PCI in the Female Patient
• Increased vascular complications
• Most marked with big sheathes / adjunctive kit
• Smaller peripheral vessels
• More frequent peripheral vascular disease
• Reduced availability of the radial (small size?)
• CTC Liverpool 2005 4 operators All PCI
• Radial access access for procedure
• Male 94% Female 90.4%
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PCI v CABG: Randomised Studies
• SYNTAX awaited
• Previous generation trials - limited female numbers
• ARTS Females 23%
• SoS Females 21%
• Higher risk profile eg SoS
• Age > 65 Male 37% Female 53%
• Unstable presn Male 19% Female 26%
• NYHA III / IV Male 26% Female 66%
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Substudy From The ‘Stent or Surgery’ Trial (SoS)
Am J Cardiol 2004;93:404-409
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PCI v CABG: SoS Substudy
• No male - female differences in
• LIMA grafts
• Total number of grafts created
• Number of PCI lesions attempted
• Number of PCI lesions revascularised
• Stent rates
• No statistical power for mortality or MACE
• Analysis of angina symptoms and QoL
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QoL Outcomes
Magnitude of improvement in QoL compared to baseline
PCI CABG
Both improve with revasc BUTMen get more improvement than women
CABG gives more gain than PCI - except at 1 year in women
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Conclusions
• Revascularisation procedures in women are
• Being performed in increasing numbers
• Have better outcomes than historic controls
• CABG and PCI outcomes less good than in males
• Not fully explained by natural history and risk
• Scope for advances in therapy to close gap
• Urgent need to improve evidence base - research
• PCI attractive option - anatomy dependent
• Only when high quality revasc is possible
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Questions and Discussion