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Acute Coronary Syndrome Management: Expected & Unexpected differences

Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010. Acute Coronary Syndrome Management: Expected & Unexpected differences. Anna Sonia Petronio Cath Lab . Cardiothoracic Dpt .

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Acute Coronary Syndrome Management: Expected & Unexpected differences

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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 Acute CoronarySyndrome Management: Expected & Unexpecteddifferences Anna Sonia Petronio CathLab. CardiothoracicDpt. Universityof Pisa

  2. Prevalence of coronary heart disease by age and sex (1999–2004) Incidence of MI by age and sex (1987–2004) ModifiedfromRosamond W, Circulation 2008

  3. 1-year Mortalityfor Acute CoronarySyndromes ModifiedfromRosamond W, Circulation 2008

  4. 5-year Mortalityfor Acute CoronarySyndromes ModifiedfromRosamond W, Circulation 2008

  5. Gender differences in CHD:Mith vs Reality?

  6. SymptomsofMen and Women Presentingwith Acute CoronarySyndromes • Women have a greater tendency to present with • atypical chest pain, dyspnoea, nausea and unexplained fatigue. • Douglas PS; NEJM 1996;334:1311-1315 • Ischaemia is more often silent in women. • Stramba-Badiale Matteoni J Hypertens 1998;16:681-688 • The proportion of unrecognized myocardial infarction is greater • in women than in men. • Kannel WB Am Heart J 1985;109:581-585 Variable All Women (n=683) All Men (n=1258) <65 years n=722 n=536 n=270 n=413 <65 years ≥65 years ≥65 years Chestpain 1123(89%)§ 665(92%) * 458(85%) * ‡ 238(88%)◊ 324(78%) ◊ ‡ 62(82%) § Dyspnea 607(48%) 338(47%) 269(50%) 137(51%) 213(52%) 562(82%) Diaphoresis 478(38%)§ 303(42%) * † 175(33%)* 83(31%) † 116(28%) 199(29%)§ Leftarmpain 374(30%) ∫ 239(33%) * 135(25%)* 79(29%) 93(23%) 172(25%)∫ Nausea 317(25%) ∫ 195(27%) † 122(23%) 98(36%) ◊ 103(25%) ◊ † 201(29%)∫ Right ArmPain 113(9%) 79(11%) * 34(6%) * 25(9%) 31(8%) 56(8%) * p<0,01, <65 ys vs ≥65 ys-oldmen ◊ p<0,01, <65 ys vs ≥65 ys-old women † p<0,01, <65 ys-oldmen vs <65 ys-old women ‡ p<0,01, ≥65 ys-oldmen vs ≥65 ys-old women ∫ p<0,05, allmen vs all women § p<0,01, allmen vs all women Arslanian-Engoren C, Am J Cardiol 2006;98:11771-8

  7. Diagnosticdelay Carabba N, Am J Cardiol 2004

  8. Prehospitaldelay: US polulation P<0,001 374 306 minutes Women men ModifiedfromArslanian-Engoren C, Am J Cardiol 2006;98:11771-8

  9. Assessmentof the ExerciseElectrocardiogram in Women Versus MenUsingTomographicMyocardialPerfusionImagingas the Reference Standard Millet TD, Am J Cardiol 2001;87:868-873

  10. Gender differences in the manifestationof ACS >12000 pts GUSTO IIb, N Engl J Med1999;341:226-32

  11. NSTEMI and Women CRUSADE 35.875 pts, 14.552 women NSTE-ACS BaselineClinicalCharacteristics MALEFEMALE AGE (yrs) 65 73 HYPERTENSION (%) 66,2 74,8 DIABETES (%) 30,6 35,6 SMOKER (%) 32 21,8 HYPERCHOLESTEROLEMIA (%) 48,8 44,5 PREVIOUS MI (%) 34 29,2 PREVIOUS PCI (%) 24,5 19,3 PREVIOUS CABG (%) 24,7 15,6 PREVIOUS HEART FAILURE (%)16,2 23,2 Blomkalns A.L. JACC 2005; 45: 832-7

  12. Characteristics of patients with AMI with and without cardiogenic shock Fang J, Am Heart J 2006;152:1035

  13. DO WE TREAT ACS IN WOMEN AS EXPECTED ?

  14. Estimated patient Cardiovascular Procedures by Sex and Age 31% PCI ModifiedfromRosamond W, Circulation 2008

  15. Acute treatment in women with ACS % ModifiedfromArslanian-Engoren C, Am J Cardiol 2006;98:11771-8

  16. The Role of Gender and Other Factors as Predictors of Not Receiving Reperfusion Therapy and of Outcome inST-SegmentElevationMyocardialInfarction Cohen M, J of Thrombosis and Thrombolysis 2005:19, 155–161

  17. NSTEMI and Women FRISC IIsubanalysis 2,457 NSTE ACS pts (749 women) FRISC II: Effectof Gender on Death or reAMI at 12 months RITA 3subanalysis: 1,810 NSTE ACS pts (682 women) Clayton T.C. et al. Eur H J 2004; 25: 1641 Lagerqvist B. et al. JACC 2001;38

  18. NSTEMI and Women TACTCS-TIMI 18: 2,220 NSTE ACS pts (757 women) Glaser R. et al. JAMA 2002; 288: 3124-29

  19. LesionCharacteristics and Procedural Data accordingto Gender Abbott JD Am J Cardiol 2007; 99: 626-631

  20. Coronary Angioplasty in woman:gender differences in coronary anatomy evaluated by IVUS ISP (mmHg/mm) <0.05 Afteradjustmentfor BSA, differencewasnotsignificantanylonger A.S.Petronio - Ital.Heart J. 2002 – suppl3:71-77

  21. Difference in Disease Presentation Obstructed coronary artery Diffused narrowing in coronary artery

  22. Assessment With Multi-Slice Computed Tomography and Gray-Scale and Virtual Histology Intravascular Ultrasound of Gender-Specific Differences in Extent and Composition of Coronary Atherosclerotic Plaques in Relation to Age Pundziute G, AmJ Cardiol2010;105:480-486

  23. Normalcoronary angiography in ACS GUSTO IIb, N Engl J Med1999;341:226-32

  24. Woman, 52 yo withtypicalchestpain

  25. Tako-tsuboCardiomyopathy • There is a strong predominance of postmenopausal women. • The seemingly increased susceptibility of women to stress-related left ventricular dysfunction and potential gender related differences in response to catecholamines is not well understood. • However, sex hormones exert important influences on the sympathetic neurohumoral axis as well as on coronary vasoreactivity. Nef HM, Heart 2007;93:1309-1315

  26. Plaque Rupture  Coronary Thrombosis burden of CHD Annual heart attacks in the US:1,107,000 Fissuration 39% 60% Plaque erosion is the major substrate for thrombosis in premenopausal women. Burke et al. Am Heart J 2001 ~1% Rupture

  27. A 64-year-old lady with arterial hypertension, hypercholesterolemia, and obesity, presented with acute myocardial infarction at a community hospital, and was transferred to our center to undergo primary coronary angioplasty. Petronio AS, Internal Journal of Cardiology Medicine 2008

  28. In-hospital mortality of women (vs men) after angioplasty for AMI based on decile of age. Paradoxically the riskincreases linearlywithdecreasingage P=0,006 OddsRatio P=0,02 P=0,75 P=0,37 <65 65-75 75-85 >85 Modifiedfrom Berger JS, Am J Cardiol 2006;98:1140-3

  29. Gender–Age Interaction in Early Mortality Following PrimaryAngioplasty for Acute Myocardial Infarction Berger JS, Am J Cardiol2006;98

  30. In-HospitalEventsaccordingto Gender P = all NS P < 0,001 Abbott JD Am J Cardiol 2007; 99: 626-631

  31. Meta-analysis of vascular complications in women versus men undergoing PCI Lansky AJ, Circulation 2005:111, 940

  32. Gender-related differences in outcome after ST-segmentelevation myocardial infarction treated by primary angioplastyand glycoprotein IIb–IIIa inhibitors: insightsfrom the EGYPT cooperation De Luca G, J ThrombThrombolysis2010

  33. Inpactoffemale gender on survival De Luca G, J ThrombThrombolysis2010

  34. Sex differences in major bleedingswithgpIIb/IIIainhibitors:Resultsfrom the CRUSADE Alexander k, Circulation2006;114 :1380

  35. Net Clinical Benefit (TRITON-TIMI 38 )Bleeding Risk Subgroups Post-hoc analysis Wiviott SD et al NEJM 357: 2001, 2007 Risk (%) + 54 Yes Prior Stroke / TIA -16 No Pint = 0.006 -1 >=75 Age -16 Pint = 0.18 < 75 +3 < 60 kg Weigth Pint = 0.36 -14 >=60 kg -13 OVERALL 0.5 1 2 Prasugrel Better Clopidogrel Better HR

  36. CAD management in women mustnotbe a men-like treatment

  37. NSTEMI and Women CRUSADE 35.875 pts, 14.552 women high-risk NSTE-ACS p<0.01* p<0.001** * * * * ** CATH CABG PCI PCI<24h CATH<24h Blomkalns A.L. JACC 2005; 45: 832-7

  38. Conclusions • Women and men with ACS are different in their risk profiles • Women with ACS are treated less aggressively than men. • Concomitant medical therapy were administered less often in women. • In patients with STEMI treated by pPCI, female gender is associated with higher mortality rate in comparison with men, and this is mainly due to their higher clinical and angiographic risk profiles. • Female sex did not emerge as an independent predictor of mortality

  39. Independentpredictorsof major/minor bleeding Lansky AJ, Circulation 2005:111, 940

  40. Picasso, 1907 Les Demoiselles D'Avignon

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