1. ACS & AMI Update WIN Program - SCAI 2010 Kimberly A. Skelding MD FSCAI FACC FAHA Associate Interventional Cardiology Geisinger Health System Danville, Pennsylvania
2. Disclosure Information ACS & AMI Update WIN Program - SCAI 2010 Kimberly A. Skelding. MD, FSCAI, FAHA, FACC Nothing to Disclose
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7. Differences Between Men and Women Undergoing PTCA Clinical Observations Anatomy Explanation ↑ unstable angina Less MV disease Spasm Lower hemoglobin ↑ angina at f/u Similar rates of incomplete revasc. Higher heart rate Higher BP Fewer repeat PTCAs Similar restenosis rates Gender bias ↑ CHF Better EF Diastolic dysfunction
8. Women Have Higher Rate of Vascular Complications After PCI Circ 2005;III;940-953
13. Bivalirudin Reduces (but does not eliminate) PCI Related Bleeding Differences Between Men and Women (n=1401) (n=3779) (p<0.001) (p<0.0001) Lancet 2007;369:;907 AJC 2009;103:1197
14. Are we still discriminating against women, or are we using good clinical judgment?
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16. Gender differences in CAD significance after diagnostic cath for ACS P<0.0001 Circ 2008;117:1792 ACC/NCDR database N = 23,382 8,708 1,596 3,725 412,918 % Female 50.2 39.1 37.6 39.4 38
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24. Gender Differences in AMI Management Persist: Get with the Guidelines Database 2001-2006 *STEMI subpopulation (28.2% women, 35.1% men, p<0.0001) Circ 2008;118:2803 Measure/Treatment Early medical therapy Aspirin within <24 h β -Blockers within <24 h Invasive procedures Cardiac catheterization PCI CABG Revascularization Any reperfusion therapy* Primary PCI Fibrinolytic Therapy Fibrinolytic therapy + PCI Timeliness of reperfusion* DTN time median (25 th -75th) min DTB time median (25 th – 75 th ) min Men (n=47 556) 93.3 87.2 56.2 52.3 9.2 60.2 73.0 61.1 6.2 5.8 39.0 95.0 Women (n=30 698) 91.0 84.7 45.6 36.1 5.4 40.9 56.3 47.3 5.1 3.9 47.0 103.0 P value <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
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27. AMI in Women: Later Presentation and Delay in Treatment - CADILLAC Primary PCI Trial- Men Women P Value N Chest pain to ER (hrs) ER to procedure (hrs) Stent use Abciximab use 1520 2.6 ± 2.5 1.9 ± 2.2 57% 54% 562 3.0 ± 2.6 2.1 ± 2.3 57% 51% - < 0.001 < 0.001 NS NS
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29. Primary PCI is Superior to Lytics in Women Meta-Analysis - 23 Randomized Trials (PCAT-2) Women Men
31. What if we treat irrespective of gender? 2 Studies ~ 2500 consecutive ACS/MI pts 30% early, aggressive revascularization strategy with 90% having angiography and 70-80% having revasculariztion Women were older, had longer pre-hospital delay, higher BP, more DM but less prior CAD events Men had more extensive CAD and more smoking history Mueller et al JACC 2002 & Mehilli et al JAMA 2002
32. The Results…… No gender differences in 30 day event, mortality or repeat revascularization Lower adjusted mortality in women with a RR of 0.65-0.67 Mehilli et al JAMA 2002
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Editor's Notes
Atherosclerotic plaque morphology differs in women and men. Acute coronary thrombosis results from 2 different types of plaque morphologies: plaque rupture and plaque erosion. Arbustini et al evaluated the prevalence of plaque erosion as a substrate for coronary thrombosis through a pathological study in patients with acute MI not treated with thrombolysis or coronary interventional procedures. This figure shows plaque erosion in 4 sections; the thrombus outlines the profile of the plaque, and there is no evidence of continuity between thrombus and plaque core. 34 Acute coronary thrombi were found in 291 hearts (98%); in 74 cases (25%) 40/107 women (37.4%) and 34/184 men (18.5%; P =.0004) the plaque substrate for thrombosis was erosion. 34 Plaque erosion is an important substrate for coronary thrombosis in patients who die of acute MI, and its prevalence is significantly higher in women than in men. 34 34. Arbustini E, Dal Bello B, Morbini P, et al. Plaque erosion is a major substrate for coronary thrombosis in acute myocardial infarction. Heart . 1999;82:269-272.
