Catheterization and Cardiovascular Interventions 85:369–370 (2015)
Editorial Comment Gender Equity in STEMI: Not So Simple! Janet Wei, MD, and Timothy D. Henry,* MD Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Key Points
Women with STEMI undergoing primary PCI have a higher risk of short-term and long-term bleeding and MACE compared to men, although increased long-term MACE is driven by increased female baseline comorbidities and treatment differences. Female sex is an easily identifiable phenotype that should alert clinicians to perform sex-specific cardiovascular risk assessment for prevention, recognize female-pattern angina symptoms, and provide education to reduce the delay between symptom onset and hospital presentation. Female sex remains an independent predictor of major bleeding and additional studies are required to determine female-specific antithrombotic regimens and catheter-access protocols.
In the past 20 years, major adverse cardiovascular outcomes (MACE) in ST-segment elevation myocardial infarction (STEMI) have improved, but a sex disparity has remained in both short-term and long-term MACE. While clinical trial and registry studies agree that women with STEMI have higher MACE rates than men, there is controversy regarding whether this difference persists after adjusting for the higher cardiovascular risk profile in women [1]. Women with STEMI are more likely to have longer delays to reperfusion, develop bleeding complications, and less likely to receive guideline-recommended pharmacotherapy. Is there a true sex difference in STEMI biology or is the higher MACE rate confounded by sex differences in baseline characteristics and treatment? In this issue of CCI, Yu et al. compare the baseline characteristics, treatment, and 3-year clinical outcomes in women versus men with STEMI in the HORIZONSAMI trial, which randomized 3,602 patients (23.4% C 2015 Wiley Periodicals, Inc. V
women) with STEMI to bivalirudin or heparin plus glycoprotein IIb/IIIa inhibitors and to percutaneous coronary intervention (PCI) with drug-eluting or bare metal stents. The results confirm previously reported data that women with STEMI have higher risk characteristics including age, hypertension, hyperlipidemia, diabetes, congestive heart failure, anemia, chronic kidney disease at presentation. Women were more likely to be treated with medical management alone (6.9% vs. 4.7%) and had significantly longer symptom-onsetto-balloon time (237.5 min vs. 218 min), driven by longer symptom-onset-to-door time. Compared to men, women had higher rates of major bleeding and MACE in-hospital, at 30 days and at 3 years. However, female sex was not an independent predictor of long-term MACE at 3 years after adjusting for differences in baseline and treatment characteristics, while it remained an independent predictor of major bleeding at 3 years. Consistent with prior studies, the authors conclude that increased long-term MACE in women with STEMI is largely explained by adverse comorbidities and treatment differences. How do we close this gender gap? Female sex is an easily identifiable phenotype that should alert clinicians to apply evidence-based guidelines for cardiovascular risk assessment, currently used less often in women. Can we improve the cardiovascular risk profile of women with early detection and prevention? Despite having more comorbidities than men, women with acute coronary syndrome have less obstructive coronary artery disease but similar number of angiographically culprit lesions and plaque burden as men [2]. In addition, while the increased comorbidities in women may be related to older age, studies indicate that young women (age
Editorial Comment Gender Equity in STEMI: Not So Simple! Janet Wei, MD, and Timothy D. Henry,* MD Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Key Points
Women with STEMI undergoing primary PCI have a higher risk of short-term and long-term bleeding and MACE compared to men, although increased long-term MACE is driven by increased female baseline comorbidities and treatment differences. Female sex is an easily identifiable phenotype that should alert clinicians to perform sex-specific cardiovascular risk assessment for prevention, recognize female-pattern angina symptoms, and provide education to reduce the delay between symptom onset and hospital presentation. Female sex remains an independent predictor of major bleeding and additional studies are required to determine female-specific antithrombotic regimens and catheter-access protocols.
In the past 20 years, major adverse cardiovascular outcomes (MACE) in ST-segment elevation myocardial infarction (STEMI) have improved, but a sex disparity has remained in both short-term and long-term MACE. While clinical trial and registry studies agree that women with STEMI have higher MACE rates than men, there is controversy regarding whether this difference persists after adjusting for the higher cardiovascular risk profile in women [1]. Women with STEMI are more likely to have longer delays to reperfusion, develop bleeding complications, and less likely to receive guideline-recommended pharmacotherapy. Is there a true sex difference in STEMI biology or is the higher MACE rate confounded by sex differences in baseline characteristics and treatment? In this issue of CCI, Yu et al. compare the baseline characteristics, treatment, and 3-year clinical outcomes in women versus men with STEMI in the HORIZONSAMI trial, which randomized 3,602 patients (23.4% C 2015 Wiley Periodicals, Inc. V
women) with STEMI to bivalirudin or heparin plus glycoprotein IIb/IIIa inhibitors and to percutaneous coronary intervention (PCI) with drug-eluting or bare metal stents. The results confirm previously reported data that women with STEMI have higher risk characteristics including age, hypertension, hyperlipidemia, diabetes, congestive heart failure, anemia, chronic kidney disease at presentation. Women were more likely to be treated with medical management alone (6.9% vs. 4.7%) and had significantly longer symptom-onsetto-balloon time (237.5 min vs. 218 min), driven by longer symptom-onset-to-door time. Compared to men, women had higher rates of major bleeding and MACE in-hospital, at 30 days and at 3 years. However, female sex was not an independent predictor of long-term MACE at 3 years after adjusting for differences in baseline and treatment characteristics, while it remained an independent predictor of major bleeding at 3 years. Consistent with prior studies, the authors conclude that increased long-term MACE in women with STEMI is largely explained by adverse comorbidities and treatment differences. How do we close this gender gap? Female sex is an easily identifiable phenotype that should alert clinicians to apply evidence-based guidelines for cardiovascular risk assessment, currently used less often in women. Can we improve the cardiovascular risk profile of women with early detection and prevention? Despite having more comorbidities than men, women with acute coronary syndrome have less obstructive coronary artery disease but similar number of angiographically culprit lesions and plaque burden as men [2]. In addition, while the increased comorbidities in women may be related to older age, studies indicate that young women (age
