1. Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010 FEDERICA ETTORI SPEDALI CIVILI EMODINAMICA BRESCIA PCI: EARLY AND LATE RESULTS COMPARABLE TO MALE GENDER?

2. 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

3. PTCA : inhospital and late mortality Lanski CIRC 2005

4. PTCA MORTALITY RATE 25-YEAR MAYO CLINIC EXPERIENCE SING JACC 2008

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

6. 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

7. CRUSADE: GP 2b/3a and major bleeding CRUSADE CIRC.2007 Dose excess PREDICTOS: - SEX - AGE - GLOM.FILTR.RATE

8. Bleeding : algorithm from 302152 PTCA NCDR Metha Circ 2007

9. Postcatheterization contrast associated acute kidney injury P NS P< 0.048 P <0.001 SIDHY AJC 2008 LESS PROSTAGLANDIN PRODUCTION MORE ATHEROEMBOLIZATION

10. Clinical restenosis rate: bare metal stent diameter diabetes no diabetes % mm CUTLIP JACC 2002 11 13 15 18 21 28 18 24 28 33 45 predictors

12. CRUSADE : NSTE ACS 35875 PTS – 41% women ( 2000-02) PROCEDURES AND CLINICAL RESULTS. BLOMKALNS JACC 2005...MA SE CORONAROPATIA SIGNIFICATIVA : UGUALE % DI PTCA TRA MASCHI E FEMMINE

13. TIMI IIIB FRISC II RITA 3 MATE TACTICS-TIMI 18

14. 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

15. PRIMARY PTCA vs LYTICS META-ANALYSIS OF 10 RANDOMIZED TRIALS 30-DAYS DEATH OR MI (%) WEAVER JAMA 1997

16. PRIMARY PTCA: in-hospital and late mortality LANSKY CIRC 2005

18. 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

19. 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

20. Mortality prediction in PCI PETERSON JACC 2010 NCDR 588,398 PCI (2004-2007) NO GENDER

21. grazie

22. Postcatheterization Retroperitoneal Bleedig P NS P 0.001 P< 0.004 P <0.001 SIDHY AJC 2008

23. PTCA : DOOR-TO-BALLOON DELAY ANGEJA AJC 2002

24. 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

25. CONS INV (%) 19.415.3 19.617.0 17.814.9 21.717.1 27.720.1 16.414.2 26.316.4 15.315.6 19.415.9 1 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 0 0.5 1 1.5 Cannon CP, et al. N Engl J Med 2001; 344: 1879 TACTIS-TIMI 18 Study Subgroup Analysis

26. 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

27. ACS: prevalence of normal or nonobstructive coronary arteries ANDERSON CIRC 2007

30. 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)

31. Elective PCI :In-hospital mortality NARINS CL.CARD 2006 NY STATE DATABASE 1999-2001 MALE = 0,3% FEMALE = 0,6%

32. 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 (0.71-1.03) 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) 0.09 0.16 0.03 0.71 0.02 0.16 0.05 0.12 0.89 0.47 0.43 0.28 0.91 RR (95% CI) Bivalirudin alone better UFH/Enox + IIb/IIIa better acuity