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Women with heart disease have a new reason to feel encouraged about the future. A study published in the June 17, 2008, issue of the Journal of the American College of Cardiology (JACC) shows that angioplasty and stenting—procedures that are used to open narrowed coronary arteries—are far more effective in women than they were in the past. Equally important, women who undergo percutaneous coronary intervention (PCI) fare just as well as men, both shortly after the procedure and over the long run.
The study, conducted at the Mayo Clinic in Rochester, MN, is expected to help dispel the notion that PCI, which has revolutionized the treatment of coronary artery disease in men, is less effective in women.
“Women should feel reassured,” said Mandeep Singh, M.D., M.P.H., an associate professor of medicine and interventional cardiologist at the Mayo Clinic. “Not only has there been significant improvement in PCI outcomes over time, women’s outcomes are similar to those of men.”
The study is likely to reassure physicians as well. “Studies have demonstrated that women are less likely than men to be referred for invasive procedures, including coronary angiography and PCI,” Dr. Singh said. “Raising awareness among physicians will help us overcome this referral bias. The decision to refer a patient for PCI should not be influenced by gender.”
Heart disease is the leading cause of death in women, accounting for some 400,000 deaths each year. In the United States, approximately 1 million PCI procedures are performed annually, some 30 percent of them in women. Earlier studies showed that PCI was riskier in women than in men. One factor in the increased risk may have been that women have smaller arteries, making PCI more difficult. In addition, women develop heart disease about a decade later than men do, so they are more likely to have additional health problems that complicate recovery after the procedure.
Since the mid-1990s, however, PCI has improved in several important ways. New stents have been introduced, the administration of anti-clotting medications has been refined, cardiologists have developed increasingly sophisticated interventional techniques, and a host of research has proven the benefits of medications such as cholesterol-lowering drugs, beta blockers and angiotensin-converting-enzyme (ACE) inhibitors in preventing future arterial blockages and heart attacks.
Dr. Singh and his colleagues set out to determine the effect of these and other improvements on mortality after PCI. For the new study, the research team analyzed data from 18,885 patients who underwent PCI at the Mayo Clinic between 1979 and 2004. Patients were divided into two groups. The “early” group comprised 7,904 patients—28 percent of them women—who were treated between 1979 and 1995. The “recent” group comprised 10,981 patients—31 percent of them women—treated between 1996 and 2004.
Women were older than men at the time of PCI, by about five years, on average. They were also significantly more likely to have severe or unstable chest pain, diabetes and high blood cholesterol levels. Nonetheless, the immediate success rate for PCI was similar in women and men, 89 percent and 90 percent, respectively.
A more telling statistic, 30-day mortality, improved significantly over time in both women and men. Among women, 30-day mortality fell from 4.4 percent in the early group to 2.9 percent in the recent group (p=0.002). Among men, 30-day mortality fell from 2.8 percent to 2.2. percent during the same time periods (p=0.04).
The researchers then analyzed the difference in outcomes between women and men, this time accounting for the greater age and incidence of health problems in women. After adjusting for these risk factors, they found no significant difference in mortality between women and men either 30 days or one year after PCI.
“This is very good news for women,” said Robert F. Wilson, M.D., a professor of interventional cardiology at the University of Minnesota and co-author of an editorial on this subject in the same issue of JACC. “Ten years ago, both coronary angioplasty and bypass surgery were riskier in women than in men. The physicians at the Mayo Clinic now report that, when the risks of age and other illnesses are accounted for, the mortality risk of coronary angioplasty in women has fallen significantly. Additionally, when factors such as diabetes and age are taken into account, the risk of death after angioplasty in women is the same as it is in men.”
“Over the last decade, we have dramatically improved the tools used for angioplasty, from new stents to keep the artery open to blood thinners to prevent clotting and heart attacks,” he said. “In addition we have learned enormously from thousands of clinical research studies that help us determine the best approach to each patient.”
Dr. Singh reports no conflicts of interest related to this study.
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