Sex-based differences in clinical outcomes after physiology-guided deferral of coronary revascularization

Invasive physiologic assessment with fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) guides coronary revascularization and supports deferral of nonischemic lesions; however, sex-specific outcomes after physiology-guided deferral remain incompletely characterized.

We performed a retrospective cohort study using the TriNetX Global Collaborative Network to identify adults undergoing invasive physiologic assessment with FFR or iFR in whom revascularization was deferred. The primary endpoint was a composite of percutaneous coronary intervention (PCI), myocardial infarction (MI), or all-cause mortality. Secondary outcomes included individual components of the composite and acute heart failure. Women and men were matched 1:1 using propensity scores. Odds ratios (OR) and hazard ratios (HR) with 95% confidence intervals (CI) were calculated.

Among 140,262 eligible patients, 47,413 matched pairs were identified after propensity score matching. Over 2 years of follow-up, women had lower odds of the composite endpoint compared with men (4192 vs 4569 events; OR 0.85, 95% CI 0.81-0.89; P < 0.001). Repeat PCI was less frequent in women (OR 0.82, 95% CI 0.78-0.86; P < 0.001), and all-cause mortality was modestly lower (OR 0.93, 95% CI 0.88-0.98; P = 0.032). MI rates were comparable (OR 1.03, 95% CI 0.97-1.09; P = 0.338). Acute heart failure occurred more frequently in women (OR 1.05, 95% CI 1.01-1.09; P = 0.046). Female sex was independently associated with lower revascularization risk (HR 0.83, 95% CI 0.79-0.87; P = 0.001).

Women had lower rates of repeat revascularization and mortality over 2 years after physiology-guided deferral, with similar MI rates but a slightly higher rate of acute heart failure compared with men.