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Cardiovascular Intervention and Therapeutics

Open Access 03-02-2025 | Myocardial Infarction | Original Article

Sex-related outcomes after percutaneous coronary intervention of in-stent restenosis

Authors: Constantin Kuna, Christian Bradaric, Mira Schroeter, Antonia Presch, Felix Voll, Sebastian Kufner, Tareq Ibrahim, Heribert Schunkert, Karl-Ludwig Laugwitz, Salvatore Cassese, Adnan Kastrati, Jens Wiebe

Published in: Cardiovascular Intervention and Therapeutics

Abstract

Limited data are available for sex-related long-term outcomes of patients treated for coronary drug-eluting stent (DES) restenosis. The aim of this observational, retrospective analysis was to close this lack of evidence. Between January 2007 and February 2021, a total of 3511 patients with 5497 in-stent restenosis (ISR) lesions were treated at two large-volume centers in Munich, Germany, of which 763 (21.7%) were female. Endpoints of interest were all-cause mortality and rates of repeat revascularization. Outcomes are presented as Kaplan–Meier event rates. Univariate and multivariate analyses were performed. Female patients were older (72.1 ± 10.4 versus 68.4 ± 10.4 years, p < 0.001) and suffered more often from diabetes (38.8% versus 34.4%, p = 0.029). There was no statistical difference regarding the clinical presentation and interventional treatment strategy. After 10 years, the risk of all-cause mortality was higher in female patients [hazard ratio (HR) 1.18 (1.02–1.35); p = 0.022]; however, after adjustment for age, the risk did not differ significantly between both sexes [adjusted HR 0.96 (0.83–1.11); p = 0.6]. Regarding target vessel revascularization (TVR) and non-target vessel revascularization (NTVR), the risk was lower in female patients [HR 0.73 (0.61–0.87); p < 0.001 and HR 0.74 (0.64–0.86); p < 0.001] even after age adjustment. No statistical differences were found regarding the risk of target lesion revascularization, target vessel myocardial infarction and stent thrombosis. In the long term, all-cause mortality after percutaneous coronary intervention of DES-ISR did not differ between both sexes after age adjustment. The risk of TVR and NTVR was lower in female patients even after age adjustment.

Graphical abstract

Timmis A, Vardas P, Townsend N, Torbica A, Katus H, De Smedt D, Gale CP, Maggioni AP, Petersen SE, Huculeci R, et al. European Society of Cardiology: cardiovascular disease statistics 2021: executive summary. Eur Heart J Qual Care Clin Outcomes. 2022;8:377–82. https://doi.org/10.1093/ehjqcco/qcac014.CrossRefPubMed

Palmerini T, Benedetto U, Biondi-Zoccai G, Della Riva D, Bacchi-Reggiani L, Smits PC, Vlachojannis GJ, Jensen LO, Christiansen EH, Berencsi K, et al. Long-term safety of drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. J Am Coll Cardiol. 2015;65:2496–507. https://doi.org/10.1016/j.jacc.2015.04.017.CrossRefPubMed

Kufner S, Joner M, Thannheimer A, Hoppmann P, Ibrahim T, Mayer K, Cassese S, Laugwitz KL, Schunkert H, Kastrati A, et al. Ten-year clinical outcomes from a trial of three limus-eluting stents with different polymer coatings in patients with coronary artery disease. Circulation. 2019;139:325–33. https://doi.org/10.1161/CIRCULATIONAHA.118.038065.CrossRefPubMed

Cassese S, Byrne RA, Schulz S, Hoppman P, Kreutzer J, Feuchtenberger A, Ibrahim T, Ott I, Fusaro M, Schunkert H, et al. Prognostic role of restenosis in 10 004 patients undergoing routine control angiography after coronary stenting. Eur Heart J. 2015;36:94–9. https://doi.org/10.1093/eurheartj/ehu383.CrossRefPubMed

Mehta PK, Wei J, Wenger NK. Ischemic heart disease in women: a focus on risk factors. Trends Cardiovasc Med. 2015;25:140–51. https://doi.org/10.1016/j.tcm.2014.10.005.CrossRefPubMed

Coughlan JJ, Raber L, Brugaletta S, Kufner S, Maeng M, Jensen LO, Ortega-Paz L, Bar S, Laugwitz KL, Madsen M, et al. Sex differences in 10-year outcomes after percutaneous coronary intervention with drug-eluting stents: insights from the DECADE cooperation. Circulation. 2023;147:575–85. https://doi.org/10.1161/CIRCULATIONAHA.122.062049.CrossRefPubMed

Bigeh A, Shekar C, Gulati M. Sex differences in coronary artery calcium and long-term CV mortality. Curr Cardiol Rep. 2020;22:21. https://doi.org/10.1007/s11886-020-1267-9.CrossRefPubMed

Ratcovich H, Alkhalil M, Beska B, Holmvang L, Lawless M, Gede Dennis Sukadana I, Wilkinson C, Kunadian V. Sex differences in long-term outcomes in older adults undergoing invasive treatment for non-ST elevation acute coronary syndrome: an ICON-1 sub-study. Int J Cardiol Heart Vasc. 2022;42:101118. https://doi.org/10.1016/j.ijcha.2022.101118.

Anderson ML, Peterson ED, Brennan JM, Rao SV, Dai D, Anstrom KJ, Piana R, Popescu A, Sedrakyan A, Messenger JC, et al. Short- and long-term outcomes of coronary stenting in women versus men: results from the National Cardiovascular Data Registry Centers for Medicare & Medicaid services cohort. Circulation. 2012;126:2190–9. https://doi.org/10.1161/CIRCULATIONAHA.112.111369.CrossRefPubMed

10.

Heer T, Hochadel M, Schmidt K, Mehilli J, Zahn R, Kuck KH, Hamm C, Bohm M, Ertl G, Hoffmeister HM, et al. Sex differences in percutaneous coronary intervention-insights from the coronary angiography and PCI registry of the German Society of Cardiology. J Am Heart Assoc. 2017. https://doi.org/10.1161/JAHA.116.004972.CrossRefPubMedPubMedCentral

11.

Kovacic JC, Mehran R, Karajgikar R, Baber U, Suleman J, Kim MC, Krishnan P, Dangas G, Sharma SK, Kini A. Female gender and mortality after percutaneous coronary intervention: results from a large registry. Catheter Cardiovasc Interv. 2012;80:514–21. https://doi.org/10.1002/ccd.23338.CrossRefPubMed

12.

Kunadian V, Qiu W, Lagerqvist B, Johnston N, Sinclair H, Tan Y, Ludman P, James S, Sarno G, National Institute for Cardiovascular Outcomes R, et al. Gender differences in outcomes and predictors of all-cause mortality after percutaneous coronary intervention (Data from United Kingdom and Sweden). Am J Cardiol. 2017;119:210–216. https://doi.org/10.1016/j.amjcard.2016.09.052.

13.

Lichtman JH, Wang Y, Jones SB, Leifheit-Limson EC, Shaw LJ, Vaccarino V, Rumsfeld JS, Krumholz HM, Curtis JP. Age and sex differences in inhospital complication rates and mortality after percutaneous coronary intervention procedures: evidence from the NCDR((R)). Am Heart J. 2014;167:376–83. https://doi.org/10.1016/j.ahj.2013.11.001.CrossRefPubMed

14.

Kosmidou I, Leon MB, Zhang Y, Serruys PW, von Birgelen C, Smits PC, Ben-Yehuda O, Redfors B, Madhavan MV, Maehara A, et al. Long-term outcomes in women and men following percutaneous coronary intervention. J Am Coll Cardiol. 2020;75:1631–40. https://doi.org/10.1016/j.jacc.2020.01.056.CrossRefPubMed

15.

Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Joint ESCAAHAWHFTFftUDoMI, Katus HA, Lindahl B, Morrow DA, et al. Third universal definition of myocardial infarction. Circulation. 2012;126:2020–35. https://doi.org/10.1161/CIR.0b013e31826e1058.

16.

DE Cutlip WS, Mehran R, et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007;115(17):2344–51. https://doi.org/10.1161/CIRCULATIONAHA.106.685313.CrossRefPubMed

17.

Garcia-Garcia HMME, Farb A, et al. Standardized end point definitions for coronary intervention trials: The Academic Research Consortium-2 consensus document. Circulation. 2018;137(24):2635–50. https://doi.org/10.1161/CIRCULATIONAHA.117.029289.CrossRefPubMed

18.

Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020;141:e139–596. https://doi.org/10.1161/CIR.0000000000000757.CrossRefPubMed

19.

Yuan X, Jiang M, Feng H, Han Y, Zhang X, Chen Y, Gao L. The effect of sex differences on neointimal characteristics of in-stent restenosis in drug-eluting stents: an optical coherence tomography study. Heliyon. 2023;9: e19073. https://doi.org/10.1016/j.heliyon.2023.e19073.CrossRefPubMedPubMedCentral

20.

Mehilli J, Kastrati A, Bollwein H, Dibra A, Schuhlen H, Dirschinger J, Schomig A. Gender and restenosis after coronary artery stenting. Eur Heart J. 2003;24:1523–30. https://doi.org/10.1016/s0195-668x(03)00320-8.CrossRefPubMed

21.

Han SH, Bae JH, Holmes DR Jr, Lennon RJ, Eeckhout E, Barsness GW, Rihal CS, Lerman A. Sex differences in atheroma burden and endothelial function in patients with early coronary atherosclerosis. Eur Heart J. 2008;29:1359–69. https://doi.org/10.1093/eurheartj/ehn142.CrossRefPubMed

22.

Lansky AJ, Ng VG, Maehara A, Weisz G, Lerman A, Mintz GS, De Bruyne B, Farhat N, Niess G, Jankovic I, et al. Gender and the extent of coronary atherosclerosis, plaque composition, and clinical outcomes in acute coronary syndromes. JACC Cardiovasc Imaging. 2012;5:S62-72. https://doi.org/10.1016/j.jcmg.2012.02.003.CrossRefPubMed

23.

Bucholz EM, Strait KM, Dreyer RP, Lindau ST, D’Onofrio G, Geda M, Spatz ES, Beltrame JF, Lichtman JH, Lorenze NP, et al. Editor’s choice-sex differences in young patients with acute myocardial infarction: a VIRGO study analysis. Eur Heart J Acute Cardiovasc Care. 2017;6:610–22. https://doi.org/10.1177/2048872616661847.CrossRefPubMed

24.

Epps KC, Holper EM, Selzer F, Vlachos HA, Gualano SK, Abbott JD, Jacobs AK, Marroquin OC, Naidu SS, Groeneveld PW, et al. Sex differences in outcomes following percutaneous coronary intervention according to age. Circ Cardiovasc Qual Outcomes. 2016;9:S16-25. https://doi.org/10.1161/CIRCOUTCOMES.115.002482.CrossRefPubMedPubMedCentral

25.

Vogel B, Acevedo M, Appelman Y, Bairey Merz CN, Chieffo A, Figtree GA, Guerrero M, Kunadian V, Lam CSP, Maas A, et al. The lancet women and cardiovascular disease commission: reducing the global burden by 2030. Lancet. 2021;397:2385–438. https://doi.org/10.1016/S0140-6736(21)00684-X.CrossRefPubMed

26.

Lichtman JH, Leifheit EC, Safdar B, Bao H, Krumholz HM, Lorenze NP, Daneshvar M, Spertus JA, D’Onofrio G. Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Circulation. 2018;137:781–90. https://doi.org/10.1161/CIRCULATIONAHA.117.031650.CrossRefPubMedPubMedCentral

27.

Kataoka Y, Puri R, Hammadah M, Duggal B, Uno K, Kapadia SR, Tuzcu EM, Nissen SE, King P, Nicholls SJ. Sex differences in nonculprit coronary plaque microstructures on frequency-domain optical coherence tomography in acute coronary syndromes and stable coronary artery disease. Circ Cardiovasc Imaging. 2016. https://doi.org/10.1161/CIRCIMAGING.116.004506.CrossRefPubMed

28.

Redfors B, Angeras O, Ramunddal T, Petursson P, Haraldsson I, Dworeck C, Odenstedt J, Ioaness D, Ravn-Fischer A, Wellin P, et al. Trends in gender differences in cardiac care and outcome after acute myocardial infarction in Western Sweden: a report from the Swedish web system for enhancement of evidence-based care in heart disease evaluated according to recommended therapies (SWEDEHEART). J Am Heart Assoc. 2015. https://doi.org/10.1161/JAHA.115.001995.CrossRefPubMedPubMedCentral

29.

Daly C, Clemens F, Lopez Sendon JL, Tavazzi L, Boersma E, Danchin N, Delahaye F, Gitt A, Julian D, Mulcahy D, et al. Gender differences in the management and clinical outcome of stable angina. Circulation. 2006;113:490–8. https://doi.org/10.1161/CIRCULATIONAHA.105.561647.CrossRefPubMed

30.

Collet JP, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42:1289–367. https://doi.org/10.1093/eurheartj/ehaa575.CrossRefPubMed

31.

D’Onofrio G, Safdar B, Lichtman JH, Strait KM, Dreyer RP, Geda M, Spertus JA, Krumholz HM. Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation. 2015;131:1324–32. https://doi.org/10.1161/CIRCULATIONAHA.114.012293.CrossRefPubMedPubMedCentral

32.

Guo Y, Yin F, Fan C, Wang Z. Gender difference in clinical outcomes of the patients with coronary artery disease after percutaneous coronary intervention: a systematic review and meta-analysis. Medicine (Baltimore). 2018;97: e11644. https://doi.org/10.1097/MD.0000000000011644.CrossRefPubMed

Title: Sex-related outcomes after percutaneous coronary intervention of in-stent restenosis
Authors: Constantin Kuna
Christian Bradaric
Mira Schroeter
Antonia Presch
Felix Voll
Sebastian Kufner
Tareq Ibrahim
Heribert Schunkert
Karl-Ludwig Laugwitz
Salvatore Cassese
Adnan Kastrati
Jens Wiebe
Publication date: 03-02-2025
Publisher: Springer Nature Singapore
Keywords: Myocardial Infarction
Acute Coronary Syndrome
Published in: Cardiovascular Intervention and Therapeutics
Print ISSN: 1868-4300
Electronic ISSN: 1868-4297
DOI: https://doi.org/10.1007/s12928-025-01092-y

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