Registry Confirms Long-Term Survival Higher in Women After Stenting

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In contemporary US practice, women have a slightly higher short-term risk after stenting than men but ultimately see better long-term survival, according to registry findings published online September 24, 2012, ahead of print in Circulation. However, drug-eluting stents (DES) are associated with better long-term outcomes in both sexes compared with bare-metal stents (BMS).

Monique Anderson, MD, of Duke University Medical Center (Durham, NC), and colleagues collected data on 426,996 patients over age 65 from both the National Cardiovascular Data Registry and Medicare inpatient claims. The patients, 42.3% of whom were women (n = 180,752), underwent stent implantation at 946 institutions between January 2004 and December 2008. About three-quarters received DES.

Women were older than men (mean age of 75.8 vs. 74.1 years) and more likely to have prior diabetes, chronic heart failure, and hypertension. Men were more likely to have hyperlipidemia, prior MI, and CABG.

Women Hold Slight Long-Term Advantage

Compared with men, women had higher in-hospital rates of all-cause mortality, bleeding, periprocedural MI, vascular complications, and cardiogenic shock (table 1).

Table 1. In-Hospital Outcomes in Women vs. Men

At 900-day follow-up, women had lower unadjusted rates of death, revascularization, and bleeding but not MI. Adjusted long-term outcomes calculated at a median follow-up of 20.4 months, however, found a significant association only between mortality and sex (table 2).

Table 2. Long-term Outcomes in Women vs. Men

 
In addition, the unadjusted long-term incidence of death was lower in patients treated with DES compared with BMS for both women (14.0% vs. 23.0%) and men (13.6% vs. 21.8%). This association between DES and improved survival remained after adjustment for both women (adjusted HR 0.78; 95% CI 0.76-0.81) and men (adjusted HR 0.77; 95% CI 0.74-0.79). DES use also improved long-term event rates for MI and revascularization in both sexes. Overall, men and women benefitted similarly from DES vs. BMS use (P for interaction = 0.63).

Causative Factors Unknown

Despite adjustment for many clinical variables, the fact that women still were at increased risk for in-hospital death suggests “that recent advances in care . . . such as the establishment of sex-based guidelines for weight-based anticoagulation therapy, availability of smaller stent-based therapies, and smaller vascular access devices are either underutilized or have not eliminated the sex-mortality gap,” the authors comment. Possible culprits for the persistent difference in outcome could relate to prehospital management of ACS, procedural differences during PCI, and use and dosage of adjunctive therapies.

Moreover, even though net adverse events were low, “sex still remains a significant risk factor for in-hospital death and complications and [the study] emphasizes the need for continued study in this area,” Dr. Anderson and colleagues write.

Although the reasons why women gain the upper hand over time are still unclear, the investigators note, “it is possible that once women are identified as having CAD (ie, after index stenting), they may receive increased aggressive secondary preventive care and attention to recurrent symptomatic CAD (as evidenced by equal rates of revascularization) thereby resulting in similar long-term clinical outcomes compared with men in the contemporary stenting era.”

As for the continuing DES vs. BMS debate, the researchers suggest that the advantage held by DES in the current study may reflect the fact that BMS were preferred in higher-risk patients. “Nevertheless, it is significant that, if confounders are operating, their effects seem to apply to men and women equally,” they conclude.

 

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Source:
Anderson M, Peterson ED, Brennan JM, et al. Acute and long-term outcomes of coronary stenting in women vs. men: Results from the National Cardiovascular Data Registry Centers for Medicare & Medicaid Services cohort. Circulation. 2012;Epub ahead of print.

 

 

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