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Tenth International Symposium
HEART FAILURE & Co.CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING
ON FEMALE DISEASES
Milano9 - 10 aprile 2010
FEDERICA ETTORI
SPEDALI CIVILI EMODINAMICA BRESCIA
PCI:
EARLY AND LATE RESULTS COMPARABLE TO MALE GENDER?
PTCA IN WOMEN
LESS PROCEDURE
LATER DIAGNOSIS
ELDERLY
MORE COMORBIDITY
MORE DIABETES (RESTENOSIS)
SMALLER BODY SURFACE AREA
SMALLER CORONARIES
CORONARY TORTUOSITY ( DIFFICULTY TRACKING,DISSECTIONS)
HEMODINAMIC :LOW CARDIAC OUTPUT DESPITE NORMAL
EF (UNABLE TO TOLLERATE CORONARY
OCCLUSION)
BLEEDING COMPLICATIONS
PTCA : inhospital and late mortality
Lanski CIRC 2005
PTCA MORTALITY RATE25-YEAR MAYO CLINIC EXPERIENCE
SING JACC 2008
PTCA:VASCULAR COMPLICATIONS
LANSKY CIRC 2005
RISK > 1.5 – 4 TIMES
VASCULAR COMPLICATIONS
JINVCARDIOL 2007;369-72
•USE SMALLER SHEATH SIZE
•USE BIVALIRUDINE OVER UFH AND GLYCOPROTEIN 2b/3a INHIBITORS
•USE THE RADIAL ARTERY
•EARLY SHEATH REMOVAL
CRUSADE: GP 2b/3a and major bleeding
CRUSADE CIRC.2007
Dose excess PREDICTOS:
- SEX
- AGE
- GLOM.FILTR.RATE
Bleeding : algorithm from 302152 PTCA NCDR
Metha Circ 2007
Postcatheterization contrast associated acute kidney injury
7,2 6,8
8,810
11
1415
19
02468
101214161820
<50ys 50-64ys 65-79ys >80ys
male
female
P NS P NS
P< 0.048
P <0.001
SIDHY AJC 2008
•LESS PROSTAGLANDIN PRODUCTION
•MORE ATHEROEMBOLIZATION
Clinical restenosis rate: bare metal stent
7 810 11 13 18
5 5 6 79 12
3 4 4 5 6 70
10
20
30
40
50
10 15 20 25 30 40
4
3
4 3,5 3 2,5
18 24 28 3345
12 1618
2129
8 10 1214 19
5 7 8 9 120
10
20
30
40
50
10 20 25 30 40
4
3
diameter
diabetesno diabetes
%
mm mm
CUTLIP JACC 2002
11 13 1518
21
2818
2428
33
45
predictors
CRUSADE : NSTE ACS35875 PTS – 41% women ( 2000-02)
PROCEDURES AND CLINICAL RESULTS
.
BLOMKALNS JACC 2005
...MA SE CORONAROPATIA SIGNIFICATIVA : UGUALE % DI PTCA TRA MASCHI E FEMMINE
TIMI IIIBFRISC IIRITA 3MATETACTICS-TIMI 18
2007 ACC/AHA UA/NSTEMI GUIDELINES
• FOR WOMEN WITH HIGH RISK FEATURES RECOMMENDATION FOR INVASIVE STRATEGY ARE SIMILAR TO THOSE FOR MEN
• IN WOMEN WITH LOW RISK FEATURES, A CONSERVATIVE STRATEGY TREATMENT IS RECOMMENDED
CLASS I INDICATION
PRIMARY PTCA vs LYTICSMETA-ANALYSIS OF 10 RANDOMIZED TRIALS
30-DAYS DEATH OR MI (%)
WEAVER JAMA 1997
PRIMARY PTCA: in-hospital and late mortality
LANSKY CIRC 2005
BERGER AJC 2006
- MORE AGGRESSIVE DISEASE (RISK FACTORS AND COMORBIDITY )
- LESS SEVERE STENOSIS (NO PRECONDITIONING)
- TREATMENT DELAY
- LESS CONCOMITANT TREATMENT
PRIMARY PTCA : EARLY MORTALITY (9015 pz N.Y. State) SEX – AGE RELATIONSHIP
BERGER PROG CARDIOVASC DIS 2006
AMI : A DIFFERENT MECHANISM?
ATHEROSCLEROTIC : PLAQUE EROSION W>M
PLAQUE RUPTURE M>W
SPONTANEOUS CORONARY DISSECTION
TAKOTSUBO
SPASM
NSTEMI : SUBENDOCARIDAL ISCHEMIA DUE TO
LVH, MICROVASCULAR DISEASE OR
ENDOTHELIAL DISFUNCTION
Mortality prediction in PCI
PETERSON JACC 2010
NCDR 588,398 PCI (2004-2007)
NO GENDER
grazie
Postcatheterization Retroperitoneal Bleedig
0,2
0,40,3
0,9
0,1
0,8
0,2
1
00,10,20,30,40,50,60,70,80,9
1
<50ys 50-64ys 65-79ys >80ys
male
female
P NS
P 0.001P< 0.004
P <0.001
SIDHY AJC 2008
PTCA : DOOR-TO-BALLOON DELAY
ANGEJA AJC 2002
AMI PRIMARY PCI FEMALE vs MALE
• SIMILAR SUCCESS RATE
• HIGHER BLEEDING COMPLICATIONS
• WOMEN OLDER THAN MAN ( 7-8 ys)
• HIGHER COMORBIDITY
• PREHOSPITAL DELAY LONGER
• SAME QUALITY of CARE
CONS INV(%) (%) 19.4 15.319.6 17.0
17.8 14.921.7 17.1
27.7 20.116.4 14.2
26.3 16.415.3 15.6
19.4 15.9
1O Endpoint %Pts
Male (66%)Female (34%)
Age < 65 yrs. (57%)Age > 65 yrs. (43%)
Diabetes (28%)No diabetes (72%)
ST * (38%)No ST (62%)
Total Population
Death, AMI, hospitalization for ACS at 6 Month
INV better CONS better
0 0.5 1 1.5
Cannon CP, et al. N Engl J Med 2001; 344: 1879
TACTIS-TIMI 18 StudySubgroup Analysis
Coronary artery Disease in Diabetics: Five critical characteristics
• Diffuse CAD
• Small vessels
• High thrombogenicity
• High rate of restenosis following PCI
• High rate of occlusive restenosis resulting
in poor prognosis
ACS: prevalence of normal or nonobstructive coronary arteries
ANDERSON CIRC 2007
Strategia Conservativa o Invasiva nella SCA: i trials
Beneficio della strategia invasiva: -Alto rischio
-PTCA precoce
-Impiego 2b/3a
Alto rischio per CABG per le donne nel FRISC II : MORTALITA’ 9,9% vs 1,2% ( p<0.001)
Elective PCI :In-hospital mortality
NARINS CL.CARD 2006
NY STATE DATABASE 1999-2001
MALE = 0,3% FEMALE = 0,6%
0 1 2
Net Clinical Outcome CompositeUFH/Enoxaparin + IIb/IIIa vs. Bivalirudin AloneUFH/Enoxaparin + IIb/IIIa vs. Bivalirudin Alone
Men (n=6444)Women (n=2771)
Diabetes (n=2585)No diabetes (n=6630)
CrCl ≥60 (n=6993)CrCl <60 (n=1644)
Age <65 (n=5051)Age ≥65 (n=4164)
Risk ratio±95% CI
Risk ratio±95% CI
BivalAlone
UFH/Enox+ IIb/IIIa
7.8%12.9%
US (n=5224)OUS (n=3991)
10.6%9.5%
8.9%16.1%
10.8%9.8%
9.5%11.6%
9.2%14.7%
11.8%11.5%
10.4%16.8%
13.7%10.9%
10.9%13.5%
P Pint
0.86 (0.71-1.03)0.88 (0.75-1.02)
0.90 (0.77-1.05)0.82 (0.68-0.98)
0.86 (0.74-0.99)0.96 (0.77-1.19)
0.79 (0.64-0.97)0.90 (0.78-1.04)
0.87 (0.75-1.00)0.86 (0.70-1.04)
0.090.09
0.160.03
0.030.71
0.020.16
0.050.12
0.89
0.47
0.43
0.28
0.91
RR (95% CI)
Bivalirudin alone betterBivalirudin alone better UFH/Enox + IIb/IIIa betterUFH/Enox + IIb/IIIa betteracuity