Same Care, Same Outcomes for Women and Men After AMICS

When women receive care equal to that received by men for acute MI complicated by cardiogenic shock (AMICS), both sexes have similar risks of mortality and need for renal replacement, according a prespecified analysis of data from the CULPRIT-SHOCK trial. This was true despite the fact that women presented with a different profile and regardless of whether they underwent complete or culprit-only revascularization.

Maria Gimenez, MD (Heart Center Leipzig, Germany, and University Hospital Basel, Switzerland), and colleagues note that while early revascularization has led to reduced mortality with AMICS, the condition still carries a high short-term mortality rate of around 50%, a risk that is especially acute for young women.

But here, after adjusting for age and other confounders, Gimenez told TCTMD, this disparity wasn’t seen—perhaps because by design all participating patients underwent PCI. “In this case, women and men were treated equally,” she explained.

“Based on these data, women and men presenting with [AMICS] and multivessel coronary artery disease should not be treated differently,” she and her coauthors conclude in their paper published recently in Circulation: Cardiovascular Interventions.

The authors of an accompanying editorial point out that registries show quite a different picture for cardiogenic shock, with women being half as likely as men to undergo revascularization.

“Such inequalities in the receipt of revascularization in the real world contribute to worse cardiogenic shock outcomes seen in females in real-world registry studies and represent an important challenge that our clinical services need to meet, to avoid unnecessary deaths in this high-risk group of patients,” Islam Y. Elgendy, MD (Massachusetts General Hospital and Harvard Medical School, Boston), Harriette G.C. Van Spall, MD (McMaster University, Hamilton, Canada), and Mamas A. Mamas, BMBCh, DPhil (Keele University, Stoke-on-Trent, England), write.

Gimenez and colleagues cite the growing interest in reducing sex disparities that exist in cardiovascular medicine. “To mitigate the suboptimal outcome of women, detection of sex-specific differences in symptom presentation, diagnosis, and management of acute MI has recently received increasing scientific attention. However, women are underrepresented in most studies addressing cardiogenic shock, and data concerning optimal management and treatment of cardiogenic shock among women are controversial.”

Women represent as many as 60% of AMICS patients—all the more reason, the editorialists emphasize, for randomized controlled trials to recruit more female participants and be powered to detect sex-specific nuances in outcome.

CULPRIT-SHOCK

CULPRIT-SHOCK enrolled patients with AMICS and multivessel disease; the trial’s main results, reported in 2017, showed that complete revascularization during the index procedure is linked to worse outcomes versus culprit-only PCI. Specifically, first performing PCI in the culprit lesion with the option to do staged procedures at a later point was linked to lower 30-day risk of death or severe renal failure leading to renal-replacement therapy, the study’s composite primary endpoint (45.9% vs 55.4%; RR 0.83; 95% CI 0.71-0.96).

Among 686 CULPRIT-SHOCK patients analyzed here, 24% were women; female patients tended to be older and more apt to have diabetes and renal insufficiency but were less likely to have a history of smoking or prior acute MI. Women also were more likely to present with STEMI, nonanterior STEMI, and to have a culprit lesion in the right coronary artery.

Female patients were less likely to receive direct stenting (OR 0.55; 95% CI 0.33-0.90) and be treated with targeted temperature management (OR 0.53; 95% CI 0.35-0.80), but were more often given intra-aortic balloon pump support (OR 2.15; 95% CI 1.05-4.40).

By 30 days, 56% of women and 49% of men had experienced a primary endpoint event, a nonsignificant difference (OR 1.29; 95% CI 0.91-1.84). Moreover, there was no interaction between patient sex and revascularization strategy: 56% of women and 42% of men who underwent culprit-only PCI had an event, as compared to 55% of women and 55% of men who underwent multivessel PCI (P for interaction = 0.11).

On multivariate analysis adjusting for age, comorbidities, and procedural factors, among other things, 30-day outcomes remained similar irrespective of patients’ sex.

For women, independent predictors of 30-day death included older age, no previous PCI, high creatinine level, and culprit lesion in the left anterior descending artery. For men, older age also was a risk factor, as were no family history of CAD and higher heart rate.

One-year outcomes also were similar between male and female patients.

Another key message, said Gimenez, is what became apparent in a comparison between women who had better versus worse outcomes. The female patients who did worse were, counterintuitively, less likely to be smokers or to have known cardiovascular disease. “Maybe we are treating those patients less aggressively or less fast because . . . they are not typical high-risk patients. And in the end they have worse outcomes” because they are overlooked, she suggested. “It could also be coincidence that we have these results.”