Contemporary Reviews in Interventional Cardiology

Cardiovascular disease remains the leading cause of death in the United States in both women and men, and each year for more than 2 decades, more women than men have died (Figure 1). In 2006, 41.3 million women (34.9%) and 38.7 million men (37.6%) were living with cardiovascular disease, reflecting mortality in 454.6 thousand women and 409.9 thousand men in 2005, with coronary heart disease responsible for 1 of every 5 deaths overall. In fact, the lifetime risk of developing coronary heart disease after age 40 is 49% in men and 32% in women. Furthermore, it is estimated that in 2009, cardiovascular disease and stroke will cost the nation $475.3 billion.1 Despite these sobering statistics, marked disparities in cardiovascular health and care, and specifically in the delivery and outcomes of coronary revascularization therapy, persist between women and men. Of the 1.3 million percutaneous coronary intervention (PCI) procedures performed in 2006, only 35% were performed in women,1 despite the known benefits of this treatment, particularly in high-risk women with acute coronary syndromes (ACS)2 and STsegment elevation myocardial infarction (STEMI).3,4 Moreover, for those women treated with PCI, unadjusted mortality (Figure 2) and (vascular and bleeding) complication rates (Figure 3) remain significantly higher than in men.5,6 Whether these sex differences are explained by pathophysiology by impaired access to guideline-recommended therapies, by biology or bias, by lack of a robust evidence base in women, or by the artificial comparison between women and men as their control group, continues to be actively debated. Certainly, the seemingly paradoxical findings of a higher prevalence of risk factors, more severe angina symptoms but a similar (or lesser) extent of epicardial coronary disease, and of a higher prevalence of congestive heart failure despite better of left ventricular systolic function in women compared with men undergoing coronary revascularization, are likely based on underlying sex differences in vascular and myocardial physiology, structure, and function.7 Given the increasing awareness by patients, the public, and healthcare providers of the prevalence and impact of coronary heart disease in women, it is timely to review the current status and issues concerning coronary intervention in women,8,9 focusing on biology and pathophysiology, access to care, and outcomes across the spectrum of coronary disease acuity. A greater understanding of the basis for the ongoing sex disparities in patients undergoing PCI may serve as a platform to improve the overall quality of cardiovascular health care in women.