Sex Differences in Revascularization, Treatment Goals, and Outcomes of Patients With Chronic Coronary Disease:
Harmony R Reynolds1, Derek D Cyr2, C Noel Bairey Merz3
1NYU Grossman School of Medicine New York NY USA.
Insights
Women with chronic coronary disease had similar outcomes to men despite less severe atherosclerosis and lower revascularization rates. The ISCHEMIA trial found no sex differences in major adverse cardiovascular events.
Area of Science:
- Cardiology
- Clinical Trials
- Sex Differences in Medicine
Background:
- Chronic coronary disease (CCD) affects women differently, often presenting at older ages with more comorbidities but less atherosclerosis.
- Understanding sex-based disparities in treatment and outcomes is crucial for equitable cardiovascular care.
- The ISCHEMIA trial provides a platform to investigate these sex differences in patients with moderate-to-severe ischemia.
Purpose of the Study:
- To explore sex differences in revascularization rates, guideline-directed medical therapy (GDMT) use, and clinical outcomes.
- To compare outcomes between men and women with chronic coronary disease undergoing invasive versus conservative management.
- To identify potential sex-specific factors influencing treatment decisions and patient results.
Main Methods:
- Analysis of data from the ISCHEMIA trial, randomizing patients with moderate-to-severe ischemia to invasive or conservative management.
- Evaluation of sex-specific differences in primary outcomes (cardiovascular death, myocardial infarction, hospitalization) and secondary outcomes.
- Assessment of revascularization rates, GDMT use, and risk factor goal attainment stratified by sex.
Main Results:
- Women comprised 22.6% of the ISCHEMIA trial participants.
- Women in the invasive group had lower revascularization rates (73.4%) compared to men (81.2%) and less extensive coronary artery disease.
- Despite lower risk factor goal attainment, women experienced similar primary (HR 0.93) and major secondary outcomes (HR 0.93) compared to men, with no significant sex-by-treatment interactions.
Conclusions:
- Women with chronic coronary disease in the ISCHEMIA trial had less severe coronary artery disease, leading to lower revascularization rates in the invasive arm.
- Despite differences in disease extent and GDMT attainment, women and men experienced comparable risk-adjusted outcomes.
- These findings highlight the importance of considering sex as a biological variable in cardiovascular disease management and research.
Background:
Women with chronic coronary disease are generally older than men and have more comorbidities but less atherosclerosis. We explored sex differences in revascularization, guideline-directed medical therapy, and outcomes among patients with chronic coronary disease with ischemia on stress testing, with and without invasive management.
Methods And Results:
The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized patients with moderate or severe ischemia to invasive management with angiography, revascularization, and guideline-directed medical therapy, or initial conservative management with guideline-directed medical therapy alone. We evaluated the primary outcome (cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) and other end points, by sex, in 1168 (22.6%) women and 4011 (77.4%) men. Invasive group catheterization rates were similar, with less revascularization among women (73.4% of invasive-assigned women revascularized versus 81.2% of invasive-assigned men; P<0.001). Women had less coronary artery disease: multivessel in 60.0% of invasive-assigned women and 74.8% of invasive-assigned men, and no ≥50% stenosis in 12.3% versus 4.5% (P<0.001). In the conservative group, 4-year catheterization rates were 26.3% of women versus 25.6% of men (P=0.72). Guideline-directed medical therapy use was lower among women with fewer risk factor goals attained. There were no sex differences in the primary outcome (adjusted hazard ratio [HR] for women versus men, 0.93 [95% CI, 0.77-1.13]; P=0.47) or the major secondary outcome of cardiovascular death/myocardial infarction (adjusted HR, 0.93 [95% CI, 0.76-1.14]; P=0.49), with no significant sex-by-treatment-group interactions.
Conclusions:
Women had less extensive coronary artery disease and, therefore, lower revascularization rates in the invasive group. Despite lower risk factor goal attainment, women with chronic coronary disease experienced similar risk-adjusted outcomes to men in the ISCHEMIA trial.
Registration:
URL: http://wwwclinicaltrials.gov. Unique identifier: NCT01471522.
