(Circulation. 1995;91:2876-2881.)
© 1995 American Heart Association, Inc.
Articles |
Long-term Outcome of Women Compared With Men After Successful Coronary Angioplasty
From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minn.
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Abstract |
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Background Women who undergo coronary angioplasty have a higher in-hospital mortality than men, although much of this difference can be accounted for by their poorer clinical characteristics at the time of their procedures. However, whether or not there are important long-term differences in outcome between women and men after coronary angioplasty is not clear.
Methods and Results A retrospective analysis was performed of 3027 consecutive patients (824 women and 2203 men) who underwent successful angioplasty and who have been followed continuously for a mean of 5.5 years (range, 0.5 to 14 years). Follow-up is 100% complete. Event-free survival was assessed by the Kaplan-Meier method, and clinical end points were also examined by Cox proportional-hazards models to account for important baseline differences when appropriate. There was a trend toward lower survival among women during follow-up, but this was not significant (P=.06). The relative risk of death among women compared with men after adjustment for baseline differences was 0.94 (CI, 0.76 to 1.15; P=NS). No significant sex differences in occurrence of Q-wave myocardial infarction were observed. Women were less likely to remain free of angina after 10 years (34% versus 37%, respectively; P=.008), but after adjustment for baseline differences, this difference was not significant (relative risk of angina, 1.07; CI, 0.95 to 1.21). Women tended to have less coronary artery bypass surgery performed during follow-up (P=.06); adjusting for baseline differences made this difference more significant (relative risk, 0.79; CI, 0.64 to 0.96; P=.02). Among patients who were not treated in the setting of acute infarction, no sex differences in survival and freedom from myocardial infarction were noted.
Conclusions After successful coronary angioplasty, the long-term prognosis for women is excellent and is similar to that observed in men. Risk-adjusted survival did not differ significantly between the sexes, but less frequent use of subsequent surgical revascularization was observed in women.
Key Words: angina • angioplasty • coronary disease • balloon • follow-up studies • myocardial infarction
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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The management of women in the United States with known or suspected coronary artery disease has recently come under close scrutiny. Recent studies have fueled controversy over the clinical management and outcome of women who present with symptoms of coronary artery disease,1 2 3 4 5 6 as well as highlighting differences in outcome after coronary revascularization procedures.7 8 9 10 11 12 13 14 15 16 17 18 19 20 As with coronary artery bypass surgery,8 10 11 12 13 14 15 women appear to have a higher in-hospital mortality than men after coronary angioplasty,7 9 16 17 18 19 20 although this difference can be largely explained by their older age, comorbid conditions, and worse clinical status at the time of treatment.7 17 Since about 30% of the approximately 400 000 coronary angioplasty procedures currently performed in the United States each year are performed in women, it is important to carefully document the long-term outcome of women undergoing this procedure.
Data concerning the long-term sex-specific outcome after coronary angioplasty have largely been based on the observations from the two National Heart, Lung, and Blood Institute's Percutaneous Transluminal Coronary Angioplasty (NHLBI PTCA) registries.9 16 In the initial registry group, symptomatic improvement was equivalent in men and women after successful coronary angioplasty, but fewer women underwent additional revascularization procedures, and women actually had better long-term survival.9 Follow-up duration in this study was short, but in the second registry study recently reported by Kelsey et al,16 4 years of follow-up data were reported. In contrast to the first study, in the second study symptom relief was less in women but overall mortality was similar for both sexes. One recent study from a tertiary institution reported that survival as well as event-free survival was better in women than in men after coronary angioplasty19 ; however, another recent study showed that the survival of women was lower after angioplasty, although this could be accounted for by their worse baseline characteristics.20
We recently reported a detailed analysis of the immediate outcome of women who underwent coronary angioplasty over a 12-year period.7 The success rate of coronary angioplasty and complication rates in women and men were similar, although the in-hospital mortality of women was 50% higher than in men, primarily as a result of their worse baseline clinical status relative to men. This present study reports the long-term outcome of those patients who had successful angioplasty, with an analysis of sex-specific differences.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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Patient Population
Details of patient selection, definitions, baseline characteristics, and immediate outcome with angioplasty have been described previously.7 Briefly, patients were selected for coronary angioplasty at our institution if they had symptoms of myocardial ischemia or myocardial infarction between 1979 and 1991. In our original study, 4071 procedures were described in 3557 patients, and analysis was performed after the patient population was divided into early (1979-1987) and late (1988-1990) cohorts. For the purposes of the present study, these two cohorts were combined. Of these 3557 patients, 3027 patients (2203 men and 824 women) had successful procedures, and they constitute the present follow-up population. Among these patients, 854 were treated within 7 days of an acute myocardial infarction. Severity of angina was classified according to the Canadian Cardiovascular Society.21 Additional data regarding noncardiac comorbid diseases were obtained according to the Diagnostic Medical Index of the Mayo Clinic and included the following diseases: cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, malignancy, renal disease, diabetes mellitus, and hypertension.
Follow-up
Follow-up of all patients dismissed from the
hospital was
obtained by an experienced data technician by telephone 6 and 12 months
after the initial procedure and continued annually thereafter.
Information regarding vital status, recurrence of angina with
functional class, occurrence of myocardial infarction (Q-wave:
Minnesota Code), and use of coronary artery bypass surgery or repeat
coronary angioplasty was sought. Mayo Clinic records were reviewed for
all patients who were followed at this institution, and verification of
events occurring at other hospitals was obtained from the attending
physicians.
Statistical Analysis
Sex differences in baseline
characteristics of the study
population were tested with Pearson's 
2 test for
discrete variables and Student's t test for continuous
variables. Event-free survival, by the Kaplan-Meier method, is reported
for patients who were dismissed from the hospital after a successful
angioplasty procedure. Differences in outcomes between the sexes were
determined by the log-rank statistic. Relative risks of various
follow-up events for sex were determined from Cox proportional-hazards
models. All pretest baseline variables were used as candidate
variables, and sex was added to the final models. Significant
differences between sexes were considered to be present when the
P value was <.05.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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The baseline clinical and angiographic characteristics for the follow-up study population are shown in Table 1
and are
very similar to those of the original population published
previously.7 Women tended to be older and to have more
severe symptoms of coronary heart disease than men but were less likely
to have had prior coronary artery bypass surgery. Despite the greater
severity of their symptoms, there was no difference in frequency of
multivessel disease, and women actually had better left ventricular
ejection fractions than men, although the difference was small
(0.63±0.13 versus 0.60±0.13, respectively; P<.001).
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Event-Free Survival of Successfully Treated Patients
Follow-up was available through March 1994, with annual follow-up
complete in 100% of patients, providing a mean follow-up duration of
5.5 years (range, 0.5 to 14 years). The Figure compares
the event-free survival for women and men. Fig 1A shows that
although
women had slightly lower survival than men, the difference was not
significant: The probability of survival at 10 years was 73% in women
versus 78% in men (P=.06). However, women were less likely
to be free of angina after 10 years compared with men (34% versus
37%, respectively; P=.008), a trend apparent after 12
months and maintained during follow-up (Fig 1B). Only 56
nonfatal
Q-wave myocardial infarctions were documented during follow-up, with no
significant difference between women and men (Fig 1C). There
was no
significant difference in the use of further angioplasty procedures
between women and men during follow-up (Fig 1D). However, there
was a
trend against the use of subsequent surgical revascularization in women
compared with men (29% versus 33% at 12 years, respectively;
P=.06) (Fig 1E). Among the 3027 successfully
treated
patients, angina was the primary indication for angioplasty in 1982
patients; none of these patients had been treated within 7 days of an
acute myocardial infarction. Long-term survival or freedom from
nonfatal Q-wave infarction was similar for women and men regardless of
severity of angina at baseline. At 10 years, the probability of
remaining free of death or nonfatal infarction was 91% for women and
83% for men (P=NS) who had mild angina at baseline, whereas
among those with severe angina, 69% of women and 75% of men
(P=NS) were likely to be free of these events.
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After
adjustment for important baseline variables, there was no
significant survival difference between women and men (relative
mortality risk, 0.94; CI, 0.76 to 1.15) (Table 2).
Similarly, adjusted risks for repeat angioplasty and the occurrence of
angina were not significantly different from those in men (Table
3). The observed trend toward less frequent use of
bypass surgery in women became more significant after adjustment for
baseline differences (relative risk, 0.79; CI, 0.64 to 0.96;
P=.02).
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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Women who undergo coronary angioplasty are at greater risk of in-hospital death than men.7 9 16 17 18 19 However, we have previously shown,7 as have others,17 that much of this risk is related to the older age of women and their worse clinical status, such as more severe angina and more cardiac failure, with only a small independent effect of female sex. Adjusting for body surface area (a surrogate of coronary artery size) appears to remove any significant sex influence on immediate mortality.7 19 In contrast, recent data from the second NHLBI PTCA registry showed that female sex appeared to be independently predictive of in-hospital mortality.16 Although there is debate as to whether female sex is independently predictive of a fatal outcome after coronary angioplasty or whether there are perhaps other, as yet unidentified, risk factors that account for these differences, the absolute increased risk of death in women cannot be ignored.
The present study extends our observations of the in-hospital
outcome of women and men to the long-term outcome of these patients.
Although a trend toward higher mortality among women was observed after
successful angioplasty (Fig 1A
), after adjustment for baseline
differences, the long-term mortality risk for women compared with men
was similar (relative risk, 0.94; CI, 0.76 to 1.15; P=NS).
Women were more likely to have recurrent angina than men, but this was
not significant after adjustment for baseline differences (relative
risk, 1.07; CI, 0.95 to 1.21; P=NS). Women were
significantly less likely to have surgical revascularization than men
(adjusted relative risk, 0.79; CI, 0.64 to 0.96; P=.02),
although there was no significant sex difference in the use of repeat
angioplasty.
Approximately 28% of the successfully treated hospital survivors had their original procedure performed within 7 days of an acute myocardial infarction. The long-term prognosis of such patients may differ from those patients who present with angina pectoris without acute infarction. Analysis performed for patients treated for angina showed that survival and freedom from nonfatal infarction were similar among women and men.
In the first NHLBI PTCA registry cohort (1977-1981), success rates were significantly lower than those currently achieved and were lower in women than in men.9 There were also more fatal and nonfatal complications among women. The long-term outcome was quite different between women and men, with better survival and less use of repeat angioplasty or surgical revascularization among women. Symptomatic relief was excellent, with no observed sex difference. However, the follow-up duration of 18 months (mean) was relatively short, and since patient selection criteria have changed dramatically since 1981 along with improved success rates, the relevance of these observations to the present time is uncertain. The observations from the second NHLBI PTCA registry cohort (1985-1986) support this contention.16 22 23 Success rates were approximately 30% higher than in the initial registry cohort and were similar in women and men, although women had a higher in-hospital mortality than men. After 4 years of follow-up of the entire cohort, whether or not coronary angioplasty had been successful, women appeared to have fared worse than men with respect to survival and angina status.16 However, unlike the in-hospital experience, female sex was not independently predictive of long-term mortality once adjustment for baseline differences had been made, although these differences could not account for the higher frequency of angina recurrence.
The observations from the second NHLBI PTCA Registry cohort are generally consistent with those from the present study. After successful coronary angioplasty, women have a higher mortality than men, although the adjusted risk is similar, and are more likely to experience a recurrence of angina and less likely to have coronary artery bypass surgery. Additional nonregistry follow-up data concerning the long-term outcome of women compared with men after coronary angioplasty were published recently. One of those studies found that women had better event-free survival than men19 ; however, the follow-up results from Emory University are consistent with our findings of higher mortality among women (although not significantly different after adjustment for baseline differences) and higher rates of angina and lower use of coronary artery bypass surgery in women.20
The lower frequency of surgery in women remains unexplained but has been observed in other similar studies.19 20 This difference was still significant after adjustment for age, diabetes, and other comorbid diseases. Although it has been suggested that women with coronary artery disease are less likely to be referred for revascularization procedures,1 2 we and others have shown that once angiography has been performed24 or an acute myocardial infarction occurs,25 revascularization is performed equally in women and men when adjusted for age. While questions of sex bias might be raised, it is important to also consider the alternative interpretation that revascularization may have been overused in men or that symptom status (a subjective observation) is a weak end point and that more meaningful data, such as exercise capacity and extent of exercise-induced ischemia, may be more reliable indicators of response to therapy. Whether bypass surgery is performed or not depends on many other factors and reflects the decisions of the cardiologist, surgeon, patient, and family as well as the social circumstances of the patient, none of which can be adequately analyzed by a retrospective statistical approach. Nevertheless, survival outcome was similar for women and men, suggesting that the observed difference in the use of subsequent surgery probably reflects appropriate patient management.
A large proportion of the procedures in the present study were performed within 7 days of an acute myocardial infarction, and although some of these were performed as direct angioplasty, these were not analyzed separately for this study. Vacek et al26 recently reported intermediate-term follow-up outcomes of 670 patients (31% women) who underwent direct angioplasty for acute infarction. Similar success rates (95% in women and 91% in men) were reported, with no significant differences during follow-up in survival, repeat procedures, or use of coronary artery bypass surgery.
In conclusion, this study demonstrates that after successful coronary angioplasty, the long-term outcome of women is similar to that of men with respect to survival and incidence of myocardial infarction. Although women tend to experience more recurrent angina than men, this difference becomes insignificant once baseline status is adjusted for. The only major difference in long-term outcome between women and men appears to be the greater use of subsequent coronary artery bypass surgery in men compared with women, for reasons that remain unclear.
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Acknowledgments |
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We express our sincere appreciation to LaVon Hammes for her help in the data collection.
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Footnotes |
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Reprint requests to Malcolm R. Bell, MB, BS, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, 200 First St SW, Rochester, MN 55905. E-mail mbell@mayo.edu.
Received August 31, 1994; revision received December 8, 1994; accepted December 27, 1994.
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