Gender differences in patients undergoing coronary stenting in current stent era.
ABSTRACT Prior studies have demonstrated worse results of women in both hospital and short-term outcomes post-percutaneous coronary intervention. However, with advanced devices like drug-eluting stents (DESs) available, there are no consistent data revealing gender impact in outcome. This study examined whether gender affected hospital outcome and showed one-year single-center patient results of coronary stenting.
The study group included 969 consecutive patients (250 women and 719 men) undergoing coronary stenting for stable or unstable angina. Clinical events were assessed for at least 1 year post-procedure.
Compared to men, women were older, presented more often with diabetes, hypertension, dyslipidemia, and lower creatinine clearance rate (Ccr); they had less percutaneous transluminal coronary angioplasty (PTCA) history, smaller vessel size, and shorter lesions. The hospital major adverse cardiovascular event (MACE) rate was 2.8% of women and 0.97% of men (P = 0.037). The one-year MACE rate was 10.0% of women and 10.4% of men (P = 0.874). After adjusting other covariates, women still had significantly higher hospital MACE rates (P = 0.034) and odds ratios (0.18; 95% confidence interval: 0.036-0.874). In women (n = 250), there was no statistically significant difference in hospital or one-year MACE between bare metal stent (BMS) and DES groups. Meanwhile, in men (n = 719), DES had a significant one-year improvement of MACE compared to BMS (P = 0.004). The female hospital MACE rate was five times greater than male results. However, there were similar one-year outcomes between women and men. DES currently have an advantage in long-term outcome.
Currently, with the use of BMS and DES, adverse hospital post-procedure cardiovascular event rate has occurred more often in women than in men. However, the MACE rate differences between women and men resolved with one year follow-up.
- SourceAvailable from: jama.jamanetwork.com[show abstract] [hide abstract]
ABSTRACT: Women with coronary artery disease (CAD) are believed to have a higher risk for adverse outcomes than men after conventional coronary interventions. The increasing use of coronary stenting has improved the outcome of patients undergoing coronary interventions, but little is known about the nature of outcomes in men vs women after this procedure. To examine whether there are sex-based differences in prognostic factors and in early and late outcomes among CAD patients undergoing coronary stent placement. Inception cohort study, at 2 tertiary referral institutions in Germany. Consecutive series of 1001 women and 3263 men with symptomatic CAD who were treated with stenting between May 1992 and December 1998. Patients who underwent stenting in the setting of acute myocardial infarction were excluded. The combined event rates of death and nonfatal myocardial infarction, assessed at 30 days and 1 year after stenting and compared by sex. Compared with men, women undergoing coronary stenting were significantly older (mean age, 69 vs 63 years) and more likely to present with diabetes, arterial hypertension, or hypercholesterolemia. Women had less extensive CAD, a less frequent history of myocardial infarction and better preserved left ventricular function than men. Women presented an excess risk of death or nonfatal myocardial infarction only during the early period after stenting: the 30-day combined event rate of death or myocardial infarction was 3.1% in women and 1.8% in men (P =.02) and the multivariate-adjusted hazard ratio (HR) for women was 2.02 (95% confidence interval [CI], 1.27-3.19). At 1 year, the outcome was similar for both women and men (combined event rate for women, 6.0%, and for men, 5.8% (P =.77); multivariate-adjusted HR for women, 1.06 [95% CI, 0.75-1.48]). There was a sex difference in the prognostic value of baseline characteristics: the strongest prognostic factors were diabetes in women and age in men. The results of this study indicate that 1-year outcomes of women with CAD undergoing coronary artery stenting are similar to those of men. Despite the similarity in outcomes, there are several sex-specific differences in baseline characteristics, clinical course after the intervention, and relative weight of prognostic factors. JAMA. 2000;284:1799-1805.JAMA The Journal of the American Medical Association 11/2000; 284(14):1799-805. · 29.98 Impact Factor
- ACC Current Journal Review 08/2005; 14(8):47–48.
- Indian Journal of Pharmacology 10/2008; 40(2):S200. · 0.58 Impact Factor
Chin Med J 2011;124(6):862-866
Gender differences in patients undergoing coronary stenting in
current stent era
Max Woo, FAN Chang-qing, Chen Yung-Lung, Hesham Husein, Fang Hsiu-Yu, Lin Cheng-Jui and Wu Chiung-Jen
Keywords: gender; hospital outcome; coronary stent
Background Prior studies have demonstrated worse results of women in both hospital and short-term outcomes
post-percutaneous coronary intervention. However, with advanced devices like drug-eluting stents (DESs) available,
there are no consistent data revealing gender impact in outcome. This study examined whether gender affected hospital
outcome and showed one-year single-center patient results of coronary stenting.
Methods The study group included 969 consecutive patients (250 women and 719 men) undergoing coronary stenting
for stable or unstable angina. Clinical events were assessed for at least 1 year post-procedure.
Results Compared to men, women were older, presented more often with diabetes, hypertension, dyslipidemia, and
lower creatinine clearance rate (Ccr); they had less percutaneous transluminal coronary angioplasty (PTCA) history,
smaller vessel size, and shorter lesions. The hospital major adverse cardiovascular event (MACE) rate was 2.8% of
women and 0.97% of men (P=0.037). The one-year MACE rate was 10.0% of women and 10.4% of men (P=0.874). After
adjusting other covariates, women still had significantly higher hospital MACE rates (P=0.034) and odds ratios (0.18;
95% confidence interval: 0.036–0.874). In women (n=250), there was no statistically significant difference in hospital or
one-year MACE between bare metal stent (BMS) and DES groups. Meanwhile, in men (n=719), DES had a significant
one-year improvement of MACE compared to BMS (P=0.004). The female hospital MACE rate was five times greater
than male results. However, there were similar one-year outcomes between women and men. DES currently have an
advantage in long-term outcome.
Conclusions Currently, with the use of BMS and DES, adverse hospital post-procedure cardiovascular event rate has
occurred more often in women than in men. However, the MACE rate differences between women and men resolved with
one year follow-up.
Chin Med J 2011;124(6):862-866
he importance of coronary artery disease of women
has been long underestimated. Women have an
apparent biological protection from coronary artery
disease before menopause, and there appears to be a 10-
to 20-year delay in the onset of coronary artery disease
among women when compared to men.1,2 Although the
incidence of myocardial infarction in women has been
rising since the 1980s, it remains lower compared to men.
Hence, gender-specific differences in the management of
coronary artery disease may exist in diagnostic
approaches and subsequent treatment strategies of
physicians.3-5 An associated gender-gap in patient
post-coronary stenting has been demonstrated in a
number of studies.6-11 The majority of studies noted
greater in-hospital mortality in women than in men, with
mortality differences resolving with longer follow-up.
The reasons for poorer outcomes in women remain
unclear, but it has been partially explained by both their
higher age and higher risk profiles. Therapy for patients
can be optimized by the knowledge of gender differences
that result in outcome variations after coronary
revascularization. With increasing
advanced interventional devices like the relatively new
drug-eluting stent, our study evaluated both the
procedural success as well as early and late outcomes of
coronary stenting among women compared to men, and
identified sex-related characteristics that may affect these
Between January 2006 and December 2008, 969
consecutive patients (250 women and 719 men)
underwent coronary stenting for stable or unstable angina
at Chang Gung Memorial Hospital in Kaohsiung. Acute
myocardial infarction patients (infarction onset within 24
hours) were not included even though this group also
Division of Cardiology, Department of Internal Medicine, Chi Mei
Medical Center, Liouying, Taiwan, China (Woo M)
Division of Cardiology, Department of Internal Medicine, Xiamen
Chang Gung Hospital, Xiamen, Fujian 361022, China (Fan CQ)
Division of Cardiology, Department of Internal Medicine, Chang
Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung
University College of Medicine, Taiwan, China (Chen YL, Husein
H, Fang HY, Lin CJ and Wu CJ)
Correspondence to: Dr. Wu Chiung-Jen, Division of Cardiology,
Department of Internal Medicine, Chang Gung Memorial
Hospital-Kaohsiung Medical Center, Chang Gung University
College of Medicine, Taiwan, China (Tel: 886-7-7317123 ext.
2363. Fax: 886-7-7317123 ext. 2355. Email: maxvic24@hotmail.
FAN Chang-qing and Max Woo contributed equally to the study.
Chinese Medical Journal 2011;124(6):862-866
underwent coronary stenting. Patients were excluded
from this study if they had procedural complications
resulted from operator or physician’s carelessness,
including wire perforation with delayed cardiac
tamponade, absent reflow phenomenon due to inadequate
dual antiplatelet agents loading.
Data collection, procedure and protocol
Patient clinical characteristics were obtained before
procedures. These included risk factors for coronary
artery disease, baseline renal function, prior history of
myocardial infarction, and prior revascularization
procedures. Angiographic variables were obtained after
the procedure; these included qualitative assessment of
coronary disease and quantitative assessment of the
culprit vessel. Type B2 and C lesions were considered
complex lesions, according to the modified classifications
of the American College of Cardiology/American Heart
recorded in the same projection prior to and after the
procedure were analyzed off-line with an automated edge
detection system. The vessel lumen and balloon diameter
measurements were performed after calibration on the
basis of the contrast-filled non-tapered catheter tip. The
target stenotic severity was ≥70%. Final interventional
strategies, including balloon pre-dilatation or primary
stenting, type, and the size of stent were left to the
physician’s discretion. Periprocedural
IIb/IIIa inhibitors, heparin
medications were used according to current standard
Patients with diabetes mellitus were defined as having a
fasting glucose concentration ≥1260 mg/L or using
anti-diabetic treatment. Hypertension patients were
defined as having a history of a systolic blood pressure of
≥140 mmHg, a diastolic pressure of ≥90 mmHg, or using
antihypertensive treatment. Patients with hyperlipidemia
were defined as having a fasting total cholesterol
concentration of ≥2000 mg/L, a fasting triglyceride
concentration of ≥1500 mg/L, or using antihyperlipidemic
treatment. Procedural success was defined as a successful
stent implantation at the desired position with residual
stenosis <30% followed by Thrombolysis in Myocardial
Infarction (TIMI) grade 3 flow in the target vessel. Major
cardiovascular adverse events (MACE) were defined as
cardiac death, non-fatal
cerebrovascular stroke and target lesion revascularization;
the latter was defined as any intervention (surgical or
percutaneous) to treat a luminal stenosis, including the
5-mm distal or proximal segments adjacent to the index
Statistical analysis was performed using SPSS 16.0 for
Windows (SPSS, Inc., Chicago, IL, USA). Continuous
variables are expressed as mean ± standard deviation (SD)
and categorical variables are expressed as percentages.
The unpaired Student’s t test was performed in the
antiplatelet and oral
analysis of continuous variables. The categorical
variables were compared using the chi-square test. We
used binary Logistic regression to access the independent
effect of sex on hospital MACE while adjusting for
potential confounders. The results were considered
statistically significant when P <0.05.
Of the 969 patients, 250 (25.8%) were women and 719
(74.2%) were men (Table 1). Compared with men,
women were nearly 4 years older and had a higher
prevalence of diabetes mellitus (P <0.001), hypertension
and hyperlipidemia, but they smoked less often (P
<0.001). Women had similar rates of prior cerebral
infarction to males but lower rates of prior myocardial
infarction or prior percutaneous transluminal coronary
angioplasty (PTCA). On admission, serum creatinine did
not reveal a statistically significant difference but the
creatinine clearance rate (Ccr) was significantly lower in
women than in men (P <0.001).
Table 1. Baseline characteristics
Variables Women (n=250)
Age (years) 67±10
DM (n (%)) 136 (54.4)
Hypertension (n (%)) 186 (74.4)
Hyperlipidemia (n (%)) 92 (36.8)
Smoking (n (%)) 9 (3.6)
Old CVA (n (%)) 24 (9.6)
Old MI (n (%)) 41 (16.4)
Prior PTCA (n (%)) 68 (27.2)
Prior CABG (n (%)) 13 (5.2)
Cr (mg/L) 14±14
Ccr (%) 53.1±25.3
Disease vessel (n (%))
One vessel 57 (22.8)
Two vessel 87 (34.8)
Triple vessel 106 (42.4)
CABG: coronary artery bypass graft surgery; Ccr: creatinine clearance rate; Cr:
creatinine; CVA: cerebral vascular accident; DM: diabetes mellitus; MI:
myocardial infarction; PTCA: percutaneous transluminal coronary angioplasty.
Angiogram findings and procedure-related
Baseline angiographic findings of the patients are shown
in Table 2. There were no significant differences between
women and men in the number or distribution of diseased
coronary vessels. Women, however, appeared to have
shorter lesions and smaller vessels. By modified
ACC/AHA classification, women appeared to have more
severe lesions (B2/C), but by online quantitative coronary
analysis (QCA), there appeared to be no significant
difference in lesion severity between the groups. In
regards to the procedure, bigger and longer stents were
used in men but there were no significant differences in
stent type choice (bare metal stent; Taxus Express, Boston,
MA, United States; Cypher, Cordis, USA; Taxus Liberte,
Boston) between women and men. As documented by
final TIMI flow and QCA, there were no apparent
differences in procedure success rate between women and
men (Table 3).
Chin Med J 2011;124(6):862-866
Table 2. Baseline angiogram data
Target vessel (n (%))
Target LAD (n (%))
Lesion class (B2/C) (n (%))
Lesion Length (mm)
Vessel Size (mm)
Pre-TIMI (n (%))
LAD: left anterior descending; LCX: left circumflex; RCA: right coronary artery;
TIMI: Thrombolysis in Myocardial Infarction.
Table 3. Procedure-related characteristics and outcomes
Variables Women (n=250)
Primary stenting (n (%)) 48 (19.2)
Stent diameter (mm) 3.08±0.35
Stent length (mm) 24.4±6.4
Stent type (n (%))
BMS 81 (32.4)
Taxus Express 79 (31.6)
Cypher 28 (11.2)
Taxus Liberte 62 (24.8)
Final balloon size (mm) 3.16±0.38
Max pressure (kPa) 1854±496
Post dilatation (n (%)) 164 (65.6)
Final TIMI flow (n (%))
TIMI 2 0 (0)
TIMI 3 250 (100.0)
Final MLD (mm) 2.96±0.61
Final stenosis (%) 11.7±8.3
BMS: bare metal stent; MLD: minimal luminal diameter.
Hospital clinical outcomes are shown in Table 4. Women
had higher revascularization rates than men, although this
was not statistically significant (P=0.055). In regards to
the total hospital MACE, women had poorer outcomes
than men (P=0.037). A multivariate analysis of factors
associated with hospital MACE is shown in Table 5.
Gender and age older than 70-year-old were independent
factors of hospital MACE. A twelve-month record of
MACE is shown in Table 6. There was no significant
difference between women and men in one year
follow-up outcomes (P=0.847).
Table 4. In hospital adverse events
Variables Women (n=250)
Adverse event (n (%))
VT/VF 4 (1.6)
Pulmonary Edema 2 (0.8)
Stroke 0 (0)
Reinfarction 2 (0.8)
Revascularization (n (%))
PTCA 0 (0)
CABG 3 (1.2)
CV death (n (%)) 4(1.6)
Hospital total MACE* (n (%)) 7 (2.8)
CV: cardiovascular; MACE: major adverse cardiovascular events; VT/VF:
ventricular tachycardia/ventricular fibrillation.
non-fatal myocardial infarction, cerebrovascular stroke and target lesion
Variables Men (n=719)
*Defined as cardiac death,
Table 5. Multivariate analysis of hospital outcome
Gender (female vs. male)
Age (≥70 years vs. <70 years)
Table 6. Twelve-month adverse events (n (%))
Adverse enents Women (n=250)
Total MACE 25 (10.0)
CV Death 5 (2.0)
MI 1 (0.4)
Stroke 2 (0.8)
TLR 17 (6.8)
CV: cardiovascular; MACE: major adverse cardiovascular events; MI:
myocardial infarction; TLR: target lesion revascularization.
This study, which examined gender differences in clinical
outcomes after coronary artery stenting, provided unique
information that distinguished this from other published
data. First, these results come from an Asian center which
provided a relatively homogenous population. Second,
this study enrolled a patient group who received advanced
interventional equipment, specifically drug-eluting stents.
Considering the large use of stenting as the main
percutaneous interventional approach in coronary artery
disease patients, and the frequently observed description
of this as an underused strategy in women, our findings
might offer practical information for the clinical
In our study, many gender differences were addressed in
characteristics such as
hyperlipidemia, and Ccr, all of which were either more
frequent or higher in value in women; smoking,
hypertension, history of coronary artery disease and
coronary intervention were more common in men.
Furthermore, considering the baseline angiogram results,
women had longer and more severe lesions compared to
men. All of these pre-intervention data may confound
post-intervention outcomes. The findings are in
agreement partly with observations reported elsewhere, in
which women presenting with first clinical symptoms are
generally older than men and have significantly higher
rates of diabetes mellitus, hypertension, but lower rates of
With the improvement of interventional devices, the
drug-eluting stent is believed to be effective in the
treatment of relatively more difficult lesions.20-23 In the
bare-metal stent era, Mehilli et al24 stated that women had
a higher 30-day rate of death or nonfatal myocardial
infarction than men (3.1% for women versus 1.8% for
men; adjusted hazard ratio 2.02); however, at one year,
the combined cardiac event rates were the same (6%
versus 5.8%). In the drug-eluting stent era, the data from
subset analyses of the randomized TAXUS IV and
SIRIUS trials of the paclitaxel and sirolimus stents
suggest a similar benefit in women and men.25,26
According to previous studies, there are significant
Factors 95% CI
age, diabetes mellitus,
Chinese Medical Journal 2011;124(6):862-866
differences between men and women in epidemiology,
diagnosis, treatment and prognosis of coronary artery
disease.27,28 The 2007
recommended that women with unstable angina or
non-ST segment elevation MI be treated in a similar
manner to men; they had the same indications for
noninvasive and invasive testing for women and men.29
In fact, women with coronary artery disease appeared to
be treated less aggressively than men.3-5 It is unknown
if intervention for women was less aggressive than men
in this study. Nevertheless, women have the characteristic
of older age, poorer renal function, and smaller vessels
size; these are common factors directing physicians to
choose conservative treatment. In the study by Zhang et
al,30 women have similar baselime characteristics but it
reveals absence of gender disparity in short-term clinical
In our study, independent predictors for hospital MACE
included gender and age older than 70 years. It is not
surprising that diabetes mellitus did not act as a powerful
predictor in our hospital outcome, similar to a previously
published study.31,32 On the other hand, Manoukian33
concluded that age and renal function have a significant
impact on post-procedure outcome in percutaneous
coronary intervention, acute coronary syndromes, and
ST-segment elevation myocardial infarction. Manoukian’s
article reminds us that although MACE rates after
percutaneous coronary intervention with stenting are
similar or higher in women compared to men in a broad
range of patient and lesion subsets, any differences might
be related to confounding risk factors and not female
This study has several limitations. A potential limitation
of our study was the lack of independent adjudication of
in-hospital adverse events, because we relied on the
recording of these events from hospital charts, cardiac
catheterization records and
Nonetheless, these are common methods in large
databases of patients with cardiac disease. Another
limitation was the exclusion of emergent percutaneous
coronary intervention procedures,
generalization of our results to emergent percutaneous
revascularization. Similarly, this study included a
relatively small number of women (n=250) based on a
single-center experience, thus it may not have sufficient
power to detect outcome difference, more not to mention
about subgroup analyses. Likewise, this study excluded
patients with acute myocardial infarction undergoing
primary stenting. Furthermore, the type of stents used
varied. All of these might limit the widespread
extrapolation to other centers and have affected our
ability to predict factors that could influence procedural
success and patient outcome.
In conclusion, with the use of bare-metal stents and drug-
eluting stents, adverse
cardiovascular event rate has occurred more often in
ACC/AHA Task Force
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women and men resolved with one year follow-up.
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(Received June 22, 2010)
Edited by WANG Mou-yue and LIU Huan