aAbbreviations: MI, myocardial infarction; TVR, target vessel revascularization; CABG, coronary artery bypass grafting. bp < 0.05 cp < 0.005
women, and an independent effect of gender on acute mortality following coronary angioplasty persists despite adjustment for differences in baseline clinical and angiographic characteristics (Fig. 10) (96,97). There is no single explanation for this increase in mortality, but it has been hypothesized that women poorly tolerate periods of transient ischemia during percutaneous revascularization procedures (109), and a higher incidence of periprocedural congestive heart failure and pulmonary edema has been reported (105). In fact, congestive heart failure has been shown to be a gender-independent predictor of mortality in both women and men undergoing coronary angioplasty (96,97).
Furthermore, during angioplasty, women mount different autonomic and hemody-namic responses to abrupt coronary occlusion than men. In a series of 140 men and 65 women undergoing single vessel percutaneous revascularization, total occlusion of a coronary artery was associated with more pronounced ST-segment changes and chest pain in women compared to men. This was associated with a higher incidence of significant bradycardia (31 vs 13%) or increase in heart rate variability (25 vs 11%) accompanied by a drop in systemic blood pressure (110).
In the New Approaches to Coronary Intervention (NACI) Registry, women undergoing percutaneous revascularization procedures with new devices were older and had more recent onset of severe or unstable chest pain than their male counterparts. Despite this adverse clinical profile, procedural success rates with respect to final percent diameter stenosis and Thrombolysis in Myocardial Ischemia (TIMI) flow grade was similar between women and men; however, women were more likely to experience procedure related complications, including coronary dissection, vascular access repair, hypotension, and transfusion, than men (92). There was no significant gender-based difference in the rate of in-hospital death, Q wave myocardial infarction, and emergent coronary bypass surgery, and gender was not an independent predictor of major adverse cardiac events. In the Bypass Angioplasty Revascularization Investigation (BARI) registry, women undergoing balloon angioplasty had similar rates of in-hospital mortality, myocardial infarction, and emergency coronary bypass surgery as men, although women had a higher incidence of periprocedural congestive heart failure and pulmonary edema (105).
To assess the influence of gender on coronary artery stent placement, 158 consecutive women undergoing coronary stenting were compared with 823 consecutive men. Women who underwent stent placement were found to have a higher in-hospital mortality, and female gender was independently associated with procedural complications (relative risk 2.4, 95% CI: 1.2-4.8) (89). Interestingly, the increased risk of death or nonfatal myocardial infarction occurred only during the first 30 d after stent placement. The combined rate of death or myocardial infarction was 3.1% for women compared to 1.8% for men, and the multivariate-adjusted hazard ratio (HR) for women was 2.02 (95% CI: 1.27-3.19) (90). Therefore, stents have not fulfilled their promise to rid of the gender difference in outcomes in patients treated with percutaneous coronary intervention.
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