Is coronary disease different in women? Why are they behaving differently as for treatemnt is concerned?
JAMA this week featured a meta-analysis adding to the growing literature supporting an underlying difference in coronary disease in men vs. women. The review included 10,000 patients, 3000 of whom were women, and looked at outcomes for NSTEMI when using an early invasive approach (catheterization) versus a more conservative approach (medical management with catheterization if necessary). Among women who were specifically identified as “biomarker positive” or “high risk” (positive CPK or troponins), an invasive strategy was associated with a 33% lower risk of combined death, MI or re-hospitalization for ACS (odds ratio 0.67, CI 0.50-0.88). Among those women who were not biomarker positive, there was no significant decrease found in this end point when comparing an invasive versus conservative management, and, in fact, a non-significant trend toward increase in death or MI was seen. Among men, the benefit of the invasive approach to NSTEMI was comparable to the “high risk” or “biomarker positive” women. Though there was also more of a benefit seen among those biomarker positive, (44% lower odds of death, MI or re-hospitalization in the biomarker positive group) unlike women, those in the biomarker negative group were not potentially harmed by early catheterization.
To summarize the findings, for a man with a NSTEMI, an early invasive approach is rational. For a woman, early catheterization may only be beneficial if they fall into a high risk group. The postulated explanation for these findings is that CAD in men is different from CAD in women, with women less likely than men to demonstrate obstructive epicardial lesions when they present. An invasive strategy is more beneficial to those with obstructive CAD. Biomarkers are one of the tools we have to help to identify a subset more likely to have obstructive CAD and thus, more likely to benefit from invasive management.
The authors state that these findings provide evidence supporting the ACC guideline that only in high-risk women (biomarker positive) should an early invasive strategy be offered.
JAMA this week featured a meta-analysis adding to the growing literature supporting an underlying difference in coronary disease in men vs. women. The review included 10,000 patients, 3000 of whom were women, and looked at outcomes for NSTEMI when using an early invasive approach (catheterization) versus a more conservative approach (medical management with catheterization if necessary). Among women who were specifically identified as “biomarker positive” or “high risk” (positive CPK or troponins), an invasive strategy was associated with a 33% lower risk of combined death, MI or re-hospitalization for ACS (odds ratio 0.67, CI 0.50-0.88). Among those women who were not biomarker positive, there was no significant decrease found in this end point when comparing an invasive versus conservative management, and, in fact, a non-significant trend toward increase in death or MI was seen. Among men, the benefit of the invasive approach to NSTEMI was comparable to the “high risk” or “biomarker positive” women. Though there was also more of a benefit seen among those biomarker positive, (44% lower odds of death, MI or re-hospitalization in the biomarker positive group) unlike women, those in the biomarker negative group were not potentially harmed by early catheterization.
To summarize the findings, for a man with a NSTEMI, an early invasive approach is rational. For a woman, early catheterization may only be beneficial if they fall into a high risk group. The postulated explanation for these findings is that CAD in men is different from CAD in women, with women less likely than men to demonstrate obstructive epicardial lesions when they present. An invasive strategy is more beneficial to those with obstructive CAD. Biomarkers are one of the tools we have to help to identify a subset more likely to have obstructive CAD and thus, more likely to benefit from invasive management.
The authors state that these findings provide evidence supporting the ACC guideline that only in high-risk women (biomarker positive) should an early invasive strategy be offered.
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