• SCAI Statement Seeks to Delineate Sex-Based Differences in Revascularization

    Current practice guidelines do not address sex-based differences in treatment for and outcomes in myocardial revascularization between women and men, according to an expert consensus statement released Friday by the Society for Cardiovascular Angiography & Interventions (SCAI).

    Alexandra Lansky, MD, of the Yale School of Medicine, Suzanne Baron, MD, MSc, of Lahey Hospital and Medical Center, Burlington, Massachusetts, and colleagues, wrote the paper, which was published in the Journal of the Society for Cardiovascular Angiography & Interventions.

    Cardiovascular disease claims the lives of nearly 8.5 million women worldwide every year. But the consensus statement found that “access and timely delivery of optimal treatment for women lags significantly behind men.”

    Based on their review of literature and data from clinical trials, utilization of common cardiovascular procedures, like percutaneous coronary intervention (PCI) and mechanical circulatory support, is “far lower in women compared with men,” the authors wrote.  

    An accompanying press release from SCAI detailed the paper’s areas of interest.

    “The paper explores gaps in evidence in several areas including the epidemiology of ischemic heart disease, diagnostic tools to guide coronary revascularization, revascularization for chronic coronary syndromes, revascularization for non-ST-elevation myocardial infarction (MI) and ST-elevation MI, and revascularization consideration for specific patient populations, vascular access in women,” the press release says.  

    For example, under the sub-heading “Invasive IVUS and OCT Imaging,” the authors noted that while women have smaller heart sizes and coronary arteries than men, there are no sex-specific recommendations for optimal computer tomography or intravascular ultrasound guidance of PCI. The authors added that intravascular imaging could be more useful in detecting and managing stent edge dissections in women than in men, as stent edge dissections are often more common and complex in women.

    The authors also offered strategies, guidelines, and suggestions for clinicians to use when treating women cardiovascular patients.    

    While evaluating women for myocardial ischemia, physicians should take care to limit ionizing radiation, as the risk for cancer is 38% higher in women compared to men, the authors noted. Cardiac magnetic resonance stress imaging should be used for its “superior diagnostic accuracy” and equal diagnostic performance in both men and women without exposure to ionizing radiation.  

    Additionally, the authors tackled the difference in clinical outcomes from a fractional flow reserve strategy versus an instantaneous wave-free ratio strategy in men and women. The data, they found, is similar in both women and men, and supports using either method to guide revascularization. While current data does not support sex-specific cut-offs for invasive functional assessments, the authors did cite research that showed how lesions of similar angiographic severity were less likely to be ischemia-producing in women.

    Using data from the SYNTAX, SYNTAX II, and EXCEL clinical trials, the authors said women with multivessel disease (MVD) and left main disease (LMD) might benefit more from coronary artery bypass graft surgery (CABG) than PCI compared with men. With that, the authors emphasized the need for contemporary studies that perform a randomized evaluation of CABG versus PCI in women with MVD, as well as in women with LMD.

    The consensus statement also includes information and guidance on coronary revascularization for chronic coronary syndromes, ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction.  

    The authors reiterated that being a woman presenting with STEMI has been associated with delays to intervention, which they say is attributable, at least in part, to atypical symptoms and slower presentation compared to men.

    “These delays and disparities in care have contributed to worse in-hospital mortality in women presenting with STEMI, particularly in younger women,” the authors wrote.

    The authors emphasized the need to develop sex-specific algorithms for the management of cardiogenic shock in women, as well as identifying sex-specific pathogenesis and risk factors that are associated with recurrence of spontaneous coronary artery dissection (SCAD) and takotsubo cardiomyopathy. Even though it accounts for less than 1% of all acute myocardial infarctions, the authors noted, approximately 90% of patients with SCAD are women between 47 and 53 years old.

    “This consensus is an international collaborative effort that highlights the knowns, the gaps and ambiguities in evidence related to sex-specific revascularization,” Lansky said in the press release. “It will inform clinicians on best practices most relevant to our female patients and [draw] attention to areas in need of additional evidence.” 

    Source:

    Lansky A, Baron SJ, Grines CL, et al. SCAI Expert Consensus Statement on Sex-Specific Considerations in Myocardial Revascularization. JSCAI 2022 Feb 4.

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