No diabetes - Gastaldi Congressi

Tenth International Symposium
HEART FAILURE & Co.
CARDIOLOGY SCIENCE UPDATE
FEMALE DOCTORS SPEAKING
ON FEMALE DISEASES
Milano
9 - 10 aprile 2010
PCI:
FEDERICA ETTORI
SPEDALI CIVILI EMODINAMICA
BRESCIA
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
RISK > 1.5 – 4 TIMES
LANSKY CIRC 2005
VASCULAR COMPLICATIONS
•USE SMALLER
SHEATH SIZE
•USE BIVALIRUDINE
OVER UFH AND
GLYCOPROTEIN 2b/3a
INHIBITORS
•USE THE RADIAL
ARTERY
•EARLY SHEATH
REMOVAL
JINVCARDIOL 2007;369-72
CRUSADE: GP 2b/3a and major bleeding
Dose excess
PREDICTOS:
- SEX
- AGE
- GLOM.FILTR.RATE
CRUSADE CIRC.2007
Bleeding : algorithm from
302152 PTCA NCDR
Metha Circ 2007
Postcatheterization contrast associated
acute kidney injury
20
18
16
14
12
10
8
6
4
2
0
P< 0.048
19
P <0.001
14
P NS
P NS
8,8
10
15
11
male
female
7,2 6,8
<50ys
50-64ys 65-79ys
SIDHY AJC 2008
>80ys
•LESS
PROSTAGLANDIN
PRODUCTION
•MORE
ATHEROEMBOLIZATION
Clinical restenosis rate: bare metal stent
predictors
diabetes
no diabetes
4 3,5 3
diameter
%
50
20
2,5
33
28
28
40
30
45
11
13
15
18
11
18
50
21
40
30
18
13
7 8
9 12
10
5
5
6
7
7
6
5
4
4
3
0
10 15 20 25 30 40
10
24
18
12
20
3
4
8
10
0
mm
5
7
10
20
24
16
10 12
28
18
8
9
25
2133
2945
19
14
3
30
12
40
4
mm
CUTLIP JACC 2002
CRUSADE : NSTE ACS
35875 PTS – 41% women ( 2000-02)
PROCEDURES AND CLINICAL RESULTS
.
...MA SE CORONAROPATIA SIGNIFICATIVA : UGUALE % DI PTCA TRA MASCHI E FEMMINE
BLOMKALNS JACC 2005
TIMI IIIB
FRISC II
RITA 3
MATE
TACTICS-TIMI 18
2007 ACC/AHA UA/NSTEMI GUIDELINES
CLASS I INDICATION
• 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
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
PRIMARY PTCA : EARLY MORTALITY (9015 pz N.Y. State)
SEX – AGE RELATIONSHIP
- MORE AGGRESSIVE DISEASE (RISK FACTORS AND COMORBIDITY )
- LESS SEVERE STENOSIS (NO PRECONDITIONING)
- TREATMENT DELAY
- LESS CONCOMITANT TREATMENT
BERGER
AJC 2006
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
NCDR 588,398 PCI (2004-2007)
NO GENDER
PETERSON JACC 2010
grazie
Postcatheterization Retroperitoneal
Bleedig
P< 0.004
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
1
P 0.001
0,9
P <0.001
0,8
P NS
0,4
male
female
0,3
0,2
0,2
0,1
<50ys
SIDHY AJC 2008
50-64ys 65-79ys
>80ys
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
TACTIS-TIMI 18 Study
Subgroup Analysis
1O Endpoint
Death, AMI, hospitalization for ACS at 6 Month
CONS
%Pts
(%)
INV
(%)
Male
Female
(66%)
(34%)
19.4
19.6
15.3
17.0
Age < 65 yrs.
Age > 65 yrs.
(57%)
(43%)
17.8
21.7
14.9
17.1
Diabetes
No diabetes
(28%)
(72%)
27.7
16.4
20.1
14.2
ST  *
No ST 
(38%)
(62%)
26.3
15.3
16.4
15.6
19.4
15.9
Total Population
0
0.5
INV better
1
1.5
CONS better
Cannon CP, et al.
N Engl J Med 2001; 344: 1879
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
Alto rischio per CABG per
le donne nel FRISC II :
MORTALITA’ 9,9% vs 1,2% (
p<0.001)
Beneficio della strategia invasiva:
-Alto rischio
-PTCA precoce
-Impiego 2b/3a
Elective PCI :In-hospital mortality
NY STATE DATABASE 1999-2001
MALE = 0,3% FEMALE = 0,6%
NARINS CL.CARD 2006
Net Clinical Outcome Composite
UFH/Enoxaparin + IIb/IIIa vs. Bivalirudin Alone
Risk ratio
±95% CI
Bival UFH/Enox
Alone + IIb/IIIa
RR (95% CI)
P
Pint
Age <65 (n=5051)
Age ≥65 (n=4164)
7.8%
12.9%
9.2%
14.7%
0.86 (0.71-1.03)
0.88 (0.75-1.02)
0.09
0.09
0.89
Men (n=6444)
Women (n=2771)
9.5%
11.6%
10.9%
13.5%
0.87 (0.75-1.00)
0.86 (0.70-1.04)
0.05
0.12
0.91
Diabetes (n=2585)
No diabetes (n=6630)
10.8%
9.8%
13.7%
10.9%
0.79 (0.64-0.97)
0.90 (0.78-1.04)
0.02
0.16
0.28
CrCl ≥60 (n=6993)
CrCl <60 (n=1644)
8.9%
16.1%
10.4%
16.8%
0.86 (0.74-0.99)
0.96 (0.77-1.19)
0.03
0.71
0.43
US (n=5224)
OUS (n=3991)
10.6%
9.5%
11.8%
11.5%
0.90 (0.77-1.05)
0.82 (0.68-0.98)
0.16
0.03
0.47
0
Bivalirudin alone better
1
2
UFH/Enox + IIb/IIIa better
acuity