Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 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 RATE 25-YEAR MAYO CLINIC EXPERIENCE SING JACC 2008

PTCA:VASCULAR COMPLICATIONS LANSKY CIRC 2005 RISK > 1.5 – 4 TIMES

VASCULAR COMPLICATIONS JINVCARDIOL 2007; 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 PTCA NCDR Metha Circ 2007

Postcatheterization contrast associated acute kidney injury P NS P< P <0.001 SIDHY AJC 2008 LESS PROSTAGLANDIN PRODUCTION MORE ATHEROEMBOLIZATION

Clinical restenosis rate: bare metal stent diameter diabetes no diabetes % mm CUTLIP JACC predictors

CRUSADE : NSTE ACS PTS – 41% women ( ) PROCEDURES AND CLINICAL RESULTS. BLOMKALNS JACC MA SE CORONAROPATIA SIGNIFICATIVA : UGUALE % DI PTCA TRA MASCHI E FEMMINE

TIMI IIIB FRISC II RITA 3 MATE TACTICS-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 LYTICS META-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 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 ( ) NO GENDER

grazie

Postcatheterization Retroperitoneal Bleedig P NS P P< 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 (%) O 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 betterCONS better Cannon CP, et al. N Engl J Med 2001; 344: 1879 TACTIS-TIMI 18 Study Subgroup 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 MALE = 0,3% FEMALE = 0,6%

Net Clinical Outcome Composite UFH/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 Bival Alone 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% 13.5% PP int 0.86 ( ) 0.88 ( ) 0.90 ( ) 0.82 ( ) 0.86 ( ) 0.96 ( ) 0.79 ( ) 0.90 ( ) 0.87 ( ) 0.86 ( ) RR (95% CI) Bivalirudin alone better UFH/Enox + IIb/IIIa better acuity