1. Keith Dawkins MD FRCP FACC Southampton University Hospital UK Is Primary Angioplasty Equally Effective in Both Men and Women ?

2. Conflicts of Interest Research Grant Support Boston Scientific Corporation Advisory Board/Consultant Abbott Vascular Boston Scientific Corporation Conor Medsystems Eli Lilly Medtronic Nycomed

7. Women in Cardiology Women in Cardiology England, Wales & N. Ireland (RCP Census) Heart 2005;91:283-289 Consultant Cardiologists (n)

8. Establish mentors for women in cardiology Encourage flexible training Establish more part-time posts Improve access for women to popular specialities (e.g. coronary intervention) Refuse to tolerate sexism or gender based discrimination in the work place

9. Eur Heart J 2000;21:1135-1140 Old

11. Are we following the flock…? Women are poorly represented in cardiology Women with cardiac disease are under investigated and under treated Most cardiologists are men All men are bastards…

12. Deaths by Cause (Women) 2004 Office of National Statistics (2005) Scotland General Register Office (2005) Northern Ireland General Register Office (2005) CHD (15%) CVA (12%)Other CVD (9%) Lung Ca (4%) Breast Ca (4%) Colorectal Ca (2%) Other Ca (14%) Respiratory Disease (14%) Injuries & Poisoning (3%) All Other Causes (22%)

13. Age-Standardised Coronary Events (Women 35-64 yrs) MONICA Project Lancet 1999;353:1547-1557 Coronary Events/100,000 population UK Glasgow UK Belfast 050100 150 200 250 300

14. Acute Myocardial Infarction (ISIS-3) Age at Presentation Percent (%) NEJM 1998;338:8-14 p<0.001

15. AMI: Cumulative Mortality ( Day 0-35) NEJM 1998;338:8-14 Mortality (%) 15 - 10 - 5 - 0 - Days after Study Entry 0 7 14 21 28 35 Women (n=6,600) Men (n=26,480) 9.1% 14.8% CI: 1.73 [1.61-1.86]

16. Plaque-fissure and intracoronary thrombus MJ Davies

17. Ruptured plaque-fissure

18. Acute myocardial infarction (transmural)

19. Complications of acute myocardial infarction Papillary Muscle Rupture VSD LV Rupture

20. Infarct Vessel Patency and Mortality GUSTO-I angiographic trial Mortality at 30 days (%) Infarct vessel patency at 90 minutes TIMI-0 TIMI-1 TIMI-2 TIMI-3 Circ 1998;97:1549-1556

21. Long-term survival after randomisation to Streptokinase: influence of myocardial blood flow JACC 1999;34:62-69 Mortality (%) Infarct vessel patency at 3-4 weeks TIMI-0/1 TIMI-2 TIMI-3 p=0.005 p=0.023 5 years 12 years

22. AHJ 2004;147:133-139 x Small numbers No gender matched controls Post hoc Sub-analysis Underpowered etc

23. Effect of Door-to-Balloon Time on Mortality: NRMI 3-4 (n=29,222) JACC 2006;47:2180-2186 Door-to-Balloon Time (mins) ≤90>90-120 >120-150 >150 12 - 10 - 8 - 6 - 4 - 2 - 0 In-Hospital Mortality (%) No Risk Factors

24. JACC 2006;47:2180-2186 Door-to-Balloon Time (mins) ≤90>90-120 >120-150 >150 12 - 10 - 8 - 6 - 4 - 2 - 0 In-Hospital Mortality (%) No Risk Factors ≥1 Risk Factors Effect of Door-to-Balloon Time on Mortality: NRMI 3-4 (n=29,222)

25. STEMI (NIRMI 3-4) Gender Prelevance (n=29,222) Prelevance (n) 70.9% 29.1% MaleFemale JACC 2006;47:2180-2186

26. Door-to-Balloon Time (mins) Mortality (%) Male Female 100 108 3.6% 6.9% p<0.0001 STEMI (NIRMI 3-4) Gender Differences (n=29,222)

27. PPCI: Relationship between Door-to-Balloon time and Gender Percentage (%) 3.9% 7.3% Male Female JAMA 2000;283:2941-2947 6.5% 9.9% Male Female p=0.05 ≤2 hours >2 hours

28. Sex-Based Differences in Early Mortality of Patients undergoing Primary Angioplasty for First Acute Myocardial Infarction Circ 2001;104:3034-3038 Variable Women N=317 Men N=727 In-Hospital Mortality 7.9%2.3% Unadjusted OR [95% CI] 3.58 [1.9-6.7]1.00 OR adjusted for age [95% CI] 2.47 [1.3-4.7]1.00 OR adjusted for age and medical history [95% CI] 2.69 [1.4-5.2]1.00 OR adjusted for age, medical history, time to treatment, and haemodynamic status [95% CI] 2.33 [1.2-4.6]1.00

29. Prognosis after Myocardial Infarction Prognosis may be worse in women per se Women are older at the time of presentation Women may have more co-morbidity (e.g. shock, hypertension, obesity, renal impairment, diabetes) Women present later and delay seeking medical attention Women are under investigated Women are under treated (less lysis, PCI or CABG)

30. Physicians recommendations for Cardiac Catheterization: Effects of Race and Gender NEJM 1999;340:618-626 Variable Odds Ratio [95% CI] P Value Male Female 1.0 0.6 [0.4-0.9] 0.02 White Black 1.0 0.6 [0.4-0.9] 0.02

32. Gender Differences in Revascularisation Rates following AMI AJC 2006;97:1722-1726 Revascularisation Rate (%) MaleFemale 32% 20% p<0.001 Mortality (%) MaleFemale 9.6% 14.5% p<0.001

33. Admission Patterns and Revascularisation Rates following AMI AJC 2006;97:1722-1726 Revasc Rate in HREV +ve hospitals (%) MaleFemale 60% 54% p<0.001 Patients admitted HREV +ve (%) MaleFemale 52% 45% p<0.001

34. Age-adjusted in-hospital mortality with STEMI Men vs. Women AJC 2006;97:1722-1726 0 0.5 1.0 1.5 1.75 Odds Ratio [95% CI] All Patients Patients in HREV +ve Patients in HREV –ve Patients REV +ve Patients REV -ve Women Fare Better Men Fare Better

35. Failure of perfusion with thrombolytics alone… Failure of perfusion with thrombolytics alone… RCA occlusion LAD occlusion

36. Coronary Reperfusion Fibrinolysis vs. Percutaneous Intervention Heart 2002;88:298-305 >90% Availability <50% Treated 54% TIMI 3 10% Reocclusion 1% CVA 25% Late Occlusion Fibrinolysis 100% 50% 0% PCI 10%Availability 5% Reocclusion 0.1% CVA >90% Treated >90% TIMI 3

37. STEMI (PPCI vs. Thrombolysis) Short-term Outcome Lancet 2003;361:13-20 Death (Non-shock) Non-fatal AMI Stroke Combined p=0.0002 p=0.0003 p<0.0001p=0.0004 p<0.0001 Frequency (%) Gender?

38. Clinical Benefits of Abciximab is Independent of Gender EPIC, EPILOG, EPISTENT meta-analysis (n=6,595) JACC 2000;36:381-386 Patients %) MaleFemale p<0.001 Bleeding with Abciximab Major Bleed Minor Bleed Event Rate (%) Male Female 11.3% 12.7% p<0.001 6.5% 5.8% p<0.001 Death, MI, TVR (30 Day) Abciximab Placebo

39. CADILLAC: Gender based Outcomes Circ 2005;111:1611-1618 STEMI <12 hrs, No shock (N=2,681) Angiographic Criteria fulfilled N=2,082 (73% men, 27% women) Randomise Primary PCI (N=518) Men = 370 Women = 148 Primary PCI + Abciximab (N=528) Men = 391 Women = 137 Multilink Stent (N=512) Men = 371 Women = 141 Multilink Stent + Abciximab (N=524) Men = 388 Women = 136

40. CADILLAC: Determinants of One Year Mortality Multivariate Predictors OR 95% CIP Female Gender 1.771.03-3.040.037 Age 1.061.03-1.09<0.0001 Killip Class 2/3 2.241.19-4.200.0003 Final TIMI 3 0.540.31-0.930.007 Pre-TIMI 3 0.680.53-0.870.012 Insulin treated DM 2.701.03-7.110.012 Sx to procedure Start 1.071.01-1.110.031 LAD vessel (vs. others) 2.381.39-4.070.035 # Diseased vessels 1.541.10-2.160.019 Circ 2005;111:1611-1618

41. CADILLAC: Baseline Variables Multivariate Predictors Men Women P Number 1520562--- Chest pain to ER (hrs) 2.6 ± 2.53.0 ± 2.6<0.001 ER to procedure (hrs) 1.9 ± 2.22.1 ± 2.3<0.001 Stent Use 57% NS Abciximab Use 54%51%NS Circ 2005;111:1611-1618

42. CADILLAC: Multivariate Predictors of One Year Mortality in Women Circ 2005;111:1611-1618 Multivariate Predictors OR 95% CIP Final MBG 0/15.151.98-13.410.0008 Final TIMI 0/1 10.471.09-100.400.0042 Creatinine 3.871.86-8.020.0003 Age (yrs) 1.091.04-1.140.0006 Hypertension 4.311.24-14.950.0212

44. Conclusions: AHA Scientific Statement There is a rising mortality burden in women with CVD PCI is performed less frequently and with greater delays in women Better understanding of this disparity should be a priority RCTs should be developed to specifically assess gender-based, ethnic and racial results of interventional therapy with appropriately matched controls Circ 2005;111:940-953

45. Why do women fare less well after Percutaneous Coronary Interventions? Increased peri-procedural complications Vascular access Bleeding Coronary dissection Abrupt vessel closure Oestrogen status Use of IIb/IIIa antagonists Smaller body habitus Women are older at the time of presentation Co-morbidity Diabetes mellitus Renal dysfunction

46. Conclusions: Mortality from STEMI is higher in women Women present later for PPCI PPCI is performed less frequently in women Outcomes following PPCI are less favourable in women Complications of PPCI are higher in women Present gender specific data are inadequate

47. XX Time for the Ladies to stop selling themselves short…

48. No more heads in the sand…