Treatment: Angioplasty in Women: Risky Business?
Women with coronary artery disease face the same issues as men: they need to be treated with a procedure to open the narrowed blood vessel(s) to prevent a heart attack.
The choices include coronary artery bypass graft (CABG) surgery or percutaneous (through the skin) coronary interventions (PCI) such as percutaneous transluminal angioplasty (PTCA), atherectomy and stents. These less-invasive treatments involve inserting a catheter – a thin, hollow tube – into the narrowed vessel and passing a device through the tube to open the artery. In PTCA, a tiny balloon is pumped up inside the artery; atherectomy involves cutting out the plaque using various devoices; stents are tiny wire coils inserted into an artery to hold it open, usually used in combination with another technology.
Leveling the playing field for woman with heart disease
Treatment for cardiovascular disease should depend on the severity of the disease and the number of vessels that are narrowed – PCI is better suited for single-vessel disease. But, despite the fact that older women experience heart disease at the same rate as men and are more likely than men to have single-vessel disease, only 35 percent of the PCI procedures performed in the United States are done on women.
Why don’t women with heart disease get referred for PCI?
One reason may be that several studies done in the late 1980s suggested that women experience high mortality and complications rates with these procedures. The numbers were significant enough to make many doctors hesitate about referring women for angioplasty or atherectomy.
The American Heart Association (AHA) wants to change that. In February 2005, the AHA reported that PCI is safe and effective in women, and that new technology is improving outcomes. How can this be? Are these procedures safe for women or not?
The explanation for AHA’s statement lies in how the data are interpreted. Contemporary studies, on which the AHA is basing its comments, adjust the data for gender differences in risk factors – the fact that women who undergo PCI are eight to 10 years older than their male counterparts, have more complicating factors such as diabetes, high cholesterol and high blood pressure and naturally have smaller coronary blood vessels.
It’s these behind-the scenes risk factors, not simply gender, that add up to a higher mortality risk with PCI for women. Take the risk factors out of the equation, and disparities in mortality mostly disappear.
Angioplasty: What is success?
Besides mortality, researchers also have looked at other measures of success. Angiographic success is an assessment of how effective the angioplasty procedure was in opening the blocked vessel. And still another measure is how effective the procedure was for relieving symptoms of coronary artery disease like chest pain.
Angioplasty success is essentially equal for men and women, about 82 to 89 percent, depending on the device used and the type of lesion. The American College of Cardiology National Cardiovascular Registry reports a clinical success rate of 96.5 percent. But, if angioplasty success is measured by symptom relief, PCI is less effective in women than in men. In fact, so is CABG – women have more chest pain than do men after either procedure.
The complication rate of an angioplasty procedure is yet another factor in evaluating success. Unfortunately, women experience higher complication rates than their male counterparts following PCI – no surprise when you consider that women come to the procedure with more underlying medical problems than men. The strongest risk factor for predicting a poor outcome in women 30 days after the procedure is diabetes.
Women also tend to have more bleeding complications related to the blood thinners given during the angioplasty procedure. They also have more vascular complications, due to the smaller size of women’s blood vessels. The situation is improving, though, as new, smaller catheters and better medications for during and after the procedure are developed. The growing use of stents also seems to be reducing complications in women compared with balloon-only angioplasty, according to the latest studies.
The restenosis problem is one issue where women and men are fairly equal. Restenosis is the re-occurrence of a blockage in a blood vessel after treatment. Prior to the invention and introduction of stents, it was a much greater problem overall, occurring in 20 to 50 percent of all patients. When stents are used in combination with a PCI, the restenosis rate drops to 10 to 30 percent. With the latest drug coated stents, these numbers are even lower.
Even though women have smaller blood vessels than men, their short-term rates for restenosis are lower, except in diabetic patients. In one study utilizing bare metal stents, restenosis rates were 28.9 percent for women and 33.9 percent for men at six months; a year after the procedure the rates were similar. For drug eluting stents, the outcomes are similar between men and women. If a woman does have restenosis, she should undergo a repeat PCI. It is unclear why men are more likely to undergo a second angioplasty procedure than women.
Women with acute coronary syndrome - such those who are having a heart attack or have unstable angina - benefit the most from PCI, according to recent studies.
In general, survival rates for CABG and PCI are the same in women with single vessel disease. And PCI does have definite pluses over CABG: no general anesthesia, no big chest incision, no need for the heart-lung machine, and shorter convalescence.
Discuss your treatment options with your physician
If you have been diagnosed with coronary artery disease, the next step should be a discussion with your cardiologist about your treatment options. He or she is the best person to evaluate your personal health and risk factors and help you make the appropriate decision.
Experience is Important
Women who undergo CABG or PCI do better in large centers with large volume and experience like the Cleveland Clinic. Catheterization, interventional procedures require special expertise. Physician credentials and experience lead to better outcomes.
Cleveland Clinic Experience:
Coronary angiography was pioneered at Cleveland Clinic in 1958 by F. Mason Sones, M.D., in whose honor the Cardiac Catheterization Laboratory is named.
In 1967, heart surgeon Rene Favaloro, M.D. pioneered coronary bypass surgery at the Cleveland Clinic. Later in 1971, Floyd D. Loop, M.D., refines operative techniques, does extensive follow-up on bypass patients, and pioneers approaches to lowering the cost of hospitalization for cardiac surgery. These and other medical milestones make the Cleveland Clinic the number one Heart Center in America
At Cleveland Clinic, we average about 10,000 diagnostic cardiac catheterizations, 3,000 interventional procedures, 3400 heart surgeries, and 1400 bypass procedures every year. Read more about our outcomes.
For questions or more information
Call the Cleveland Clinic Heart Center Resource and Information Center Nurse at 216.445.9288 or toll-free 866.289.6911. For an appointment with a Cleveland Clinic women’s heart specialist, call 800.223.2273, ext. 4-6697 or locally 216.444.6697. Or, you may use the Contact Us form to contact us by email.
- Smith SC, Feldman TE, Hirshfeld JW et al. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention—Summary Article . J Am Coll Cardiol 2006; 47:216-35. (PDF)
- Lansky AJ, Hochman JS, Ward PA et al. Percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professionals from the American Heart Association. Circulation 2005; Feb 22;111(7):940-53.
- Peterson ED, Lansky AJ, Kramer J et al. Effect of gender on the outcomes of contemporary percutaneous coronary intervention. Am J Cardiol 2001;88:359-64.
- Smith SCJ, Dove JT, Jacobs AK, et al. ACC/AHA guidelines for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol. 2001;37:2239i-lxvi.
- Weintraub WS, Wenger NK, Kosinski AS et al. Percutaneous transluminal coronary angioplasty in women compared with men. J Am Coll Cardiol 1994;24:81-90.
- AHA urges earlier diagnoses, referrals for PCI in women, 2/01/2005, American Heart Association
- Elective PCI, Professional View: Heart Healthy Women, 5/02/06, hearthealthywomen.org
Reviewed by Dr. Cho
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