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Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE

Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010. PCI: EARLY AND LATE RESULTS COMPARABLE TO MALE GENDER?. FEDERICA ETTORI SPEDALI CIVILI EMODINAMICA BRESCIA. PTCA IN WOMEN.

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Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE

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  1. Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010 PCI: EARLY AND LATE RESULTS COMPARABLE TO MALE GENDER? FEDERICA ETTORI SPEDALI CIVILI EMODINAMICA BRESCIA

  2. 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

  3. PTCA : inhospital and late mortality Lanski CIRC 2005

  4. PTCA MORTALITY RATE25-YEAR MAYO CLINIC EXPERIENCE SING JACC 2008

  5. PTCA:VASCULAR COMPLICATIONS RISK > 1.5 – 4 TIMES LANSKY CIRC 2005

  6. 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

  7. CRUSADE: GP 2b/3a and major bleeding Dose excess PREDICTOS: - SEX - AGE - GLOM.FILTR.RATE CRUSADE CIRC.2007

  8. Bleeding : algorithm from 302152 PTCA NCDR Metha Circ 2007

  9. Postcatheterization contrast associated acute kidney injury P< 0.048 P <0.001 P NS P NS • LESS PROSTAGLANDIN PRODUCTION • MORE ATHEROEMBOLIZATION SIDHY AJC 2008

  10. Clinical restenosis rate: bare metal stent predictors diabetes no diabetes 45 % diameter 33 28 28 24 18 21 18 15 13 11 mm mm CUTLIP JACC 2002

  11. CRUSADE : NSTE ACS35875 PTS – 41% women ( 2000-02) PROCEDURES AND CLINICAL RESULTS . ...MA SE CORONAROPATIA SIGNIFICATIVA : UGUALE % DI PTCA TRA MASCHI E FEMMINE BLOMKALNS JACC 2005

  12. TIMI IIIB FRISC II RITA 3 MATE TACTICS-TIMI 18

  13. 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

  14. PRIMARY PTCA vs LYTICS META-ANALYSIS OF 10 RANDOMIZED TRIALS 30-DAYS DEATH OR MI (%) WEAVER JAMA 1997

  15. PRIMARY PTCA: in-hospital and late mortality LANSKY CIRC 2005

  16. 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

  17. 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

  18. Mortality prediction in PCI NCDR 588,398 PCI (2004-2007) NO GENDER PETERSON JACC 2010

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  20. Postcatheterization Retroperitoneal Bleedig P< 0.004 P 0.001 P <0.001 P NS SIDHY AJC 2008

  21. PTCA : DOOR-TO-BALLOON DELAY ANGEJA AJC 2002

  22. 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

  23. Death, AMI, hospitalization for ACS at 6 Month CONS INV (%) (%) 19.4 15.3 19.6 17.0 17.8 14.9 21.7 17.1 27.7 20.1 16.4 14.2 26.3 16.4 15.3 15.6 19.4 15.9 1O Endpoint %Pts Male (66%) Female (34%) Age < 65 yrs. (57%) Age > 65 yrs. (43%) Diabetes(28%) No diabetes (72%) ST  * (38%) No ST  (62%) Total Population 0 0.5 1 1.5 INV better CONS better Cannon CP, et al. N Engl J Med 2001; 344: 1879 TACTIS-TIMI 18 StudySubgroup Analysis

  24. 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

  25. ACS: prevalence of normal or nonobstructive coronary arteries ANDERSON CIRC 2007

  26. 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

  27. Elective PCI :In-hospital mortality NY STATE DATABASE 1999-2001 MALE = 0,3% FEMALE = 0,6% NARINS CL.CARD 2006

  28. 11.8% 0.02 0.09 0.05 0.87 (0.75-1.00) 0.79 (0.64-0.97) 0.86 (0.74-0.99) 10.9% 10.6% 13.7% 7.8% 0.90 (0.77-1.05) 8.9% 0.16 0.03 9.2% 10.4% 9.5% 10.8% 0.86 (0.71-1.03) 11.6% 0.16 0.12 10.9% 12.9% 9.5% 16.1% 9.8% 14.7% 11.5% 0.03 0.82 (0.68-0.98) 13.5% 0.09 0.71 0.86 (0.70-1.04) 0.90 (0.78-1.04) 0.88 (0.75-1.02) 0.96 (0.77-1.19) 16.8% Net Clinical Outcome Composite UFH/Enoxaparin + IIb/IIIa vs. Bivalirudin Alone UFH/Enox + IIb/IIIa Risk ratio ±95% CI Bival Alone RR (95% CI) P Pint Age <65 (n=5051) Age ≥65 (n=4164) 0.89 Men (n=6444) Women (n=2771) 0.91 Diabetes (n=2585) No diabetes (n=6630) 0.28 CrCl ≥60 (n=6993)CrCl <60 (n=1644) 0.43 US (n=5224)OUS (n=3991) 0.47 Bivalirudin alone better UFH/Enox + IIb/IIIa better acuity

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