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