This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bell, M. R. Articles by Holmes, D. R. Search for Related Content PubMed PubMed Citation Articles by Bell, M. R. Articles by Holmes, D. R., Jr

(Circulation. 1995;91:2876-2881.)
© 1995 American Heart Association, Inc.

Articles

Long-term Outcome of Women Compared With Men After Successful Coronary Angioplasty

Malcolm R. Bell, MB, BS, FRACP; Diane E. Grill, MS; Kirk N. Garratt, MD; Peter B. Berger, MD; Bernard J. Gersh, MB, ChB, DPhil; David R. Holmes, Jr, MD

From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minn.

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
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

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
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.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
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.

	Results

Top Abstract Introduction Methods Results Discussion References

 
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).

View this table: [in this window] [in a new window]   Table 1. Baseline Characteristics of 3027 Patients Who Were Followed After Successful Coronary Angioplasty

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.

View larger version (28K): [in this window] [in a new window]   Figure 1. Graphs comparing the long-term outcome of women to men after successful coronary angioplasty, with respect to (A) survival, (B) freedom from recurrence of angina, (C) freedom from Q-wave myocardial infarction (MI), (D) freedom from use of repeat coronary angioplasty (PTCA), and (E) freedom from use of coronary artery bypass graft surgery (CABG).

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).

View this table: [in this window] [in a new window]   Table 2. Relative Risk Ratios for Long-term Mortality1

View this table: [in this window] [in a new window]   Table 3. Univariate and Multivariate Relative Risk Ratios (Women Versus Men) for Other Follow-up Events1

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
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.

	Acknowledgments

 
We express our sincere appreciation to LaVon Hammes for her help in the data collection.

	Footnotes

 
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.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med. 1991;325:221-225. [Abstract]
   
2. Steingart RM, Packer M, Hamm P, Coglianese ME, Gersh B, Geltman EM, Sollano J, Katz S, Moye L, Basta LL, Lewis SJ, Gottlieb SS, Bernstein V, McEwan P, Jacobson K, Brown EJ, Kukin ML, Kantrowitz NE, Pfeffer MA, for the Survival and Ventricular Enlargement Investigators. Sex differences in the management of coronary artery disease. N Engl J Med. 1991; 325:226-230.
   
3. Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in the treatment and outcome of acute myocardial infarction: results from the Myocardial Infarction Triage and Intervention Registry. Arch Intern Med. 1992;152:972-976. [Abstract]
   
4. Jenkins JS, Flaker GC, Nolte B, Price LA, Morris D, Kurz J, Petroski GF. Causes of higher in-hospital mortality in women than in men after acute myocardial infarction. Am J Cardiol. 1994;73:319-322. [Medline] [Order article via Infotrieve]
   
5. Tobin JN, Wassertheil SS, Wexler JP, Steingart RM, Budner N, Lense L, Wachspress J. Sex bias in considering coronary bypass surgery. Ann Intern Med. 1987;107:19-25.
   
6. Mark DB, Shaw LK, DeLong ER, Califf RM, Pryor DB. Absence of sex bias in the referral of patients for cardiac catheterization. N Engl J Med. 1994;330:1101-1106. [Abstract/Free Full Text]
   
7. Bell MR, Holmes DR Jr, Berger PB, Garratt KN, Bailey KR, Gersh BJ. The changing in-hospital mortality of women undergoing percutaneous transluminal coronary angioplasty. JAMA. 1993;269:2091-2095. [Abstract]
   
8. Khan SS, Nessim S, Gray R, Czer LS, Chaux A, Matloff J. Increased mortality of women in coronary artery bypass surgery: evidence for referral bias. Ann Intern Med. 1990;112:561-567.
   
9. Cowley MJ, Mullin SM, Kelsey SF, Kent KM, Gruentzig AR, Detre KM, Passamani ER. Sex differences in early and long-term results of coronary angioplasty in the NHLBI PTCA Registry. Circulation. 1985;71:90-97. [Abstract/Free Full Text]
   
10. Rahimtoola SH, Bennett AJ, Grunkemeier GL, Block P, Starr A. Survival at 15 to 18 years after coronary bypass surgery for angina in women. Circulation. 1993;88(pt 2):II-71-II-78.
    
11. Weintraub WS, Wenger NK, Jones EL, Craver JM, Guyton RA. Changing clinical characteristics of coronary surgery patients: differences between men and women. Circulation. 1993;88(pt 2):II-79-II-86.
    
12. O'Connor GT, Morton JR, Diehl MJ, Olmstead EM, Coffin LH, Levy DG, Maloney CT, Plume SK, Nugent W, Malenka DJ, Hernandez F, Clough R, Birkmeyer J, Marrin CAS, Leavitt BJ. Differences between men and women in hospital mortality associated with coronary artery bypass graft surgery. Circulation. 1993;88(pt 1):2104-2110.
    
13. Douglas JS Jr, King SB III, Jones EL, Craver JM, Bradford JB, Hatcher CR Jr. Reduced efficacy of coronary bypass surgery in women. Circulation. 1981;64(suppl II):II-11-II-16.
    
14. Loop FD, Golding LR, MacMillan JP, Cosgrove DM, Lytle BW, Sheldon WC. Coronary artery surgery in women compared with men: analyses of risks and long-term results. J Am Coll Cardiol. 1983;1:383-390. [Abstract]
    
15. Fisher LD, Ward Kennedy J, Davis KB, Maynard C, Fritz JK, Kaiser G, Myers WO, and the participating CASS Clinics. Association of sex, physical size, and operative mortality after coronary artery bypass in the Coronary Artery Surgery Study (CASS). J Thorac Cardiovasc Surg. 1982;84:334-341. [Abstract]
    
16. Kelsey SF, James M, Holubkov AL, Holubkov R, Cowley MJ, Detre KM, and Investigators from the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. Results of percutaneous transluminal coronary angioplasty in women: 1985–1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry. Circulation. 1993;87:720-727. [Abstract/Free Full Text]
    
17. Kahn JK, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV, Shimshak TM, Ligon RW, Hartzler GO. Comparison of procedural results and risks of coronary angioplasty in men and women for conditions other than acute myocardial infarction. Am J Cardiol. 1992;69:1241-1242. [Medline] [Order article via Infotrieve]
    
18. Ellis SG, Roubin GS, King SB III, Douglas JS Jr, Shaw RE, Stertzer SH, Myler RK. In-hospital cardiac mortality after acute closure after coronary angioplasty: analysis of risk factors from 8,207 procedures. J Am Coll Cardiol. 1988;11:211-216. [Abstract]
    
19. Arnold AM, Mick MJ, Piedmonte MR, Simpfendorfer C. Gender differences for coronary angioplasty. Am J Cardiol. 1994;74:18-21. [Medline] [Order article via Infotrieve]
    
20. Weintraub WS, Wenger NK, Kosinski AS, Douglas JS Jr, Liberman HA, Morris DC, King SB III. Percutaneous transluminal coronary angioplasty in women compared with men. J Am Coll Cardiol. 1994;24:81-90. [Abstract]
    
21. Campeau L. Grading of angina pectoris. Circulation. 1976;54:522-523. [Medline] [Order article via Infotrieve]
    
22. Detre K, Holubkov R, Kelsey S, Cowley M, Kent K, Williams D, Myler R, Faxon D, Holmes DJ, Bourassa M, Block P, Gosselin A, Bentivoglio L, Leatherman L, Dorros G, King SI, Galichia J, Al-Bassam M, Leon M, Robertson T, Passamani E, and the coinvestigators of the National Heart, Lung, and Blood Institute's Percutaneous Transluminal Coronary Angioplasty registry. Percutaneous transluminal coronary angioplasty in 1985-1986 and 1977-1981: the National Heart, Lung, and Blood Institute Registry. N Engl J Med. 1988;318:265-270. [Abstract]
    
23. Holmes DR Jr, Holubkov R, Vlietstra RE, Kelsey SF, Reeder GS, Dorros G, Williams DO, Cowley MJ, Faxon DP, Kent KM, Bentivoglio LG, Detre K, and the co-investigators of The National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. Comparison of complications during percutaneous transluminal coronary angioplasty from 1977 to 1981 and from 1985 to 1986: the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. J Am Coll Cardiol. 1988;12:1149-1155. [Abstract]
    
24. Bell MR, Gersh BJ, Berger PB, Bailey KR, Mullany CJ, Holmes DR Jr. Is there a gender bias in referral for revascularization procedures after coronary angiography? J Am Coll Cardiol. In press.
    
25. Krumholz HM, Douglas PS, Lauer MS, Pasternak RC. Selection of patients for coronary angiography and coronary revascularization early after myocardial infarction: is there evidence for a gender bias? Ann Intern Med. 1992;116:785-790.
    
26. Vacek JL, Rosamond TL, Kramer PH, Crouse LJ, Porter CB, Robuck OW, White JL, Beauchamp GD. Sex-related differences in patients undergoing direct angioplasty for acute myocardial infarction. Am Heart J. 1994;126:521-525.
    

This article has been cited by other articles:

				M. Singh, C. S. Rihal, B. J. Gersh, V. L. Roger, M. R. Bell, R. J. Lennon, A. Lerman, and D. R. Holmes Jr Mortality differences between men and women after percutaneous coronary interventions. A 25-year, single-center experience. J. Am. Coll. Cardiol., June 17, 2008; 51(24): 2313 - 2320. [Abstract] [Full Text] [PDF]

				J.-A. Eastwood, L. Doering, J. Roper, and R. D. Hays Uncertainty and Health-Related Quality of Life 1 Year After Coronary Angiography Am. J. Crit. Care., May 1, 2008; 17(3): 232 - 242. [Abstract] [Full Text] [PDF]

				A. J. Lansky, R. A. Costa, M. Mooney, M. G. Midei, H. K. Lui, W. Strickland, R. Mehran, M. B. Leon, M. E. Russell, S. G. Ellis, et al. Gender-based outcomes after paclitaxel-eluting stent implantation in patients with coronary artery disease J. Am. Coll. Cardiol., April 19, 2005; 45(8): 1180 - 1185. [Abstract] [Full Text] [PDF]

				W.-C. Chang, P. Kaul, C. M. Westerhout, M. M. Graham, Y. Fu, T. Chowdhury, and P. W. Armstrong Impact of Sex on Long-term Mortality From Acute Myocardial Infarction vs Unstable Angina Arch Intern Med, November 10, 2003; 163(20): 2476 - 2484. [Abstract] [Full Text] [PDF]

				J. Mehilli, A. Kastrati, H. Bollwein, A. Dibra, H. Schuhlen, J. Dirschinger, and A. Schomig Gender and restenosis after coronary artery stenting Eur. Heart J., August 2, 2003; 24(16): 1523 - 1530. [Abstract] [Full Text] [PDF]

				B Brorsson, S J Bernstein, R H Brook, and L Werko Quality of life of patients with chronic stable angina before and four years after coronary revascularisation compared with a normal population Heart, February 1, 2002; 87(2): 140 - 145. [Abstract] [Full Text] [PDF]

				S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2239 - 2239. [Full Text] [PDF]

				J. Mehilli, A. Kastrati, J. Dirschinger, H. Bollwein, F.-J. Neumann, and A. Schomig Differences in Prognostic Factors and Outcomes Between Women and Men Undergoing Coronary Artery Stenting JAMA, October 11, 2000; 284(14): 1799 - 1805. [Abstract] [Full Text] [PDF]

				J.E Roeters van Lennep, A.H Zwinderman, H.W.O Roeters van Lennep, H.E Westerveld, H.W.M Plokker, A.A Voors, A.V.G Bruschke, and E.E van der Wall Gender differences in diagnosis and treatment of coronary artery disease from 1981 to 1997. No evidence for the Yentl syndrome Eur. Heart J., June 1, 2000; 21(11): 911 - 918. [Abstract] [PDF]

				G. S. Aldea, J. M. Gaudiani, O. M. Shapira, A. K. Jacobs, J. Weinberg, A. L. Cupples, H. L. Lazar, and R. J. Shemin Effect of gender on postoperative outcomes and hospital stays after coronary artery bypass grafting Ann. Thorac. Surg., April 1, 1999; 67(4): 1097 - 1103. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bell, M. R. Articles by Holmes, D. R. Search for Related Content PubMed PubMed Citation Articles by Bell, M. R. Articles by Holmes, D. R., Jr