Sex and Outcomes After Percutaneous Coronary Intervention: A Cause for Concern for Young Women and Those With ST‐Segment Elevation Myocardial Infarction?

S ince the first reports describing mortality differences in women and men with acute myocardial infarction nearly 25 years ago, there has been a plethora of information regarding sex differences in the presentation, management, and outcomes of patients with coronary artery disease (CAD). The data are overwhelming and not uncommonly, the results are often discrepant. So, what do we know about CAD in women? We know that there are clear differences by sex in the presentation of patients with CAD. Women are typically about 5 to 10 years older than men and are significantly more likely to have a history of hypertension and diabetes mellitus and to be in heart failure on presentation to the hospital. Fewer women than men are smokers. Women are less aggressively treated. As such, women have a higher in-hospital, 30-day, and long-term mortality as compared with men. Yet, many of the differences in outcomes have been attributed to sex differences in the presentation and treatment of these patients. Although most studies have shown that after adjusting for the higher rate of comorbidities and therapies given, women and men have similar outcomes, some reports have suggested persistently higher adjusted odds for adverse events in women as compared with men. In this issue of JAHA, the authors looked at sex differences in procedural events and hospital mortality among women and men referred for percutaneous coronary intervention (PCI) in 218 hospitals in Germany from 2007 to 2009. The advantage of this analysis relates to the robustness of the data collected, providing detailed information regarding procedural characteristics and outcomes for 185 312 patients. Since the analysis is inclusive of all patients referred for PCI, it avoids some of the potential for treatment bias and permits a more uniform comparison of women and men with CAD undergoing revascularization for predefined clinical scenarios. Because of the extremely large sample size, the authors were able to compare sex differences in outcome among patients presenting with myriad disease conditions including stable ischemic heart disease, non ST-elevation acute coronary syndrome, and STsegment elevation myocardial infarction (STEMI) as well as patients getting PCI for cardiogenic shock. In addition, the authors were able to examine difference in outcome for women and men in different age groups. The study demonstrated that PCI success rates were generally higher in women than men (although success of PCI was similar in women and men with STEMI). However, women were less likely to undergo a complex PCI procedure. Irrespective of the clinical scenario, vascular complications following PCI were higher in women. As compared to men, age-adjusted hospital mortality was significantly higher in women undergoing PCI for STEMI or cardiogenic shock, but mortality in women and men undergoing PCI for stable symptoms or non ST-elevation acute coronary syndrome was similar. When outcomes in women and men were compared for patients in discrete age groups, mortality was higher in younger women undergoing PCI as comparedwith youngermen, while older women andmen had similar mortality. The findings in this study emphasize 3 very important and consistent themes noted in the literature regarding the sex differences in outcome of patients with CAD: