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Nick Curzen PhD FRCP FESC Wessex Cardiothoracic Unit Southampton

The Use of Adjuvant Medical Therapies During PCI: Are There Gender Differences?. Nick Curzen PhD FRCP FESC Wessex Cardiothoracic Unit Southampton. Yeah, right!. PCI: Women versus Men?. Well established that……………………. Female coronary arteries smaller Relatively protected by oestrogen

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Nick Curzen PhD FRCP FESC Wessex Cardiothoracic Unit Southampton

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  1. The Use of Adjuvant Medical Therapies During PCI: Are There Gender Differences? Nick Curzen PhD FRCP FESC Wessex Cardiothoracic Unit Southampton

  2. Yeah, right!

  3. PCI: Women versus Men?

  4. Well established that…………………….. • Female coronary arteries smaller • Relatively protected by oestrogen • Women have increased clotting tendency • Women present older and later with ACS • Women’s symptoms less often typical • ETT less useful • Invasive assessment & revascularisation underutilised • Worse outcome after CABG • Higher complication rates in acute MI • Less invasive investigation and treatment • More complications – especially bleeding • Less secondary prevention

  5. Well established that…………………….. • Female coronary arteries smaller • Relatively protected by oestrogen • Women have increased clotting tendency • Women present older and later with ACS • Women’s symptoms less often typical • ETT less useful • Invasive assessment & revascularisation underutilised • Worse outcome after CABG • Higher complication rates in acute MI

  6. Well established that…………………….. • Female coronary arteries smaller • Relatively protected by oestrogen • Women have increased clotting tendency • Women present older and later with ACS • Women’s symptoms less often typical • ETT less useful • Invasive assessment & revascularisation underutilised • Worse outcome after CABG • Higher complication rates in acute MI • Higher complication rates in PCI

  7. Well established that…………………….. • Female coronary arteries smaller • Relatively protected by oestrogen • Women have increased clotting tendency • Women present older and later with ACS • Women’s symptoms less often typical • ETT less useful • Invasive assessment & revascularisation underutilised • Worse outcome after CABG • Higher complication rates in acute MI • Higher complication rates in PCI

  8. GPIIbIIIa Inhibitors With PCI… How Do Women Do?

  9. ACS+ PCI + Women: The Role of GPIIbIIIa inhibitors

  10. Aggressive Revasc in ACS: Do Women Receive the Same Treatment?

  11. Aggressive Revasc in ACS: Do Women Do Less Well? …… And Is It Drug Related

  12. TACTICS - Study Death, AMI, Rehosp. : 6 months 19.4% 15.9% 30 days OR=0.51 P=0.002 20 conserv. 16 % patients 12 O.R. 0.78 95% CI (0.62, 0.97) p=0.025 invasive 8 4 • Same degree of benefit in women and men • All patients received IIb IIIa inhibitor 0 0 1 2 3 4 5 6 Months

  13. FRISC II (Fragmin & Fast Revascularisation during Instability in Coronary artery Disease) • Different outcome in women and men • Low use of IIb IIAa (10%)

  14. So - Why are the results of TACTICS-TIMI18 discrepant with FRIC-II & RITA-3?

  15. TACTICS - Troponin T Death, AMI, Rehosp. 6 Months CONS INV p<0.001 OR=0.52 Interaction P<0.001 p=NS (%) N= 414 396 463 495 TnT > 0.01 ng/ml (54% of Pts TnT +)

  16. Maybe the nature of the vascular inflammatory response is different in women…… & maybe there are also other subtler differences…………..?

  17. Platelets 2006;17:385-92. A Novel Fifteen Minute Test for Assessment of Individual Time-dependent Clotting Responses to Aspirin and Clopidogrel using Modified Thrombelastography. A Hobson1, G Petley2, K Dawkins1, N Curzen1,4 AUC of AA channel 6 hrs post aspirin. (p=0.038)

  18. AUC of the TEG fibrin channel at baseline. (P=0.00002) Baseline AUC15 of TEG Thrombin channel. P=0.004 Thanks to Alex Hobson AUC of AA channel at baseline. (P=0.005) Baseline responses to ADP stimulation (p=0.001)

  19. STEMI: Women & Thrombolytics……… & PCI?

  20. STEMI: Women & Thrombolytics……… & PCI?

  21. PCI & Bivalirudin in Women

  22. Are Other Adjunctive Therapies Gender-Fair?

  23. SUMMARY • Women are not the same as men • Nor are their coronary arteries • They have higher baseline platelet reactivity • They present differently • They are investigated and treated less aggressively • They may be given less secondary prevention Rx • They have more complications in MI • They have more complications with PCI … especially bleeding • In ACS: they have different levels of some markers of inflammation • They may respond less well to early invasive revasc in ACS? • But they have the same benefit in ACS PCI from IIb IIIa inhibitors • Women are difficult to understand but we need to try harder

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