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Gender Disparities in Outcomes of Invasive versus Conservative Strategies for Coronary Artery Disease: Insights from the ISCHEMIA Trial

30 Apr 2024
Gender differences in coronary artery disease

The highly impactful International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial investigated the effectiveness of invasive (INV) versus conservative (CON) strategies for managing stable coronary artery disease. While the trial showed similar risk of cardiac events between INV and CON strategies, outcomes based on participant sex were not initially reported. It is well known that there are differences in the pathophysiology of coronary artery disease and its clinical presentation between sexes. Furthermore, variations in the efficacy, safety, and adoption of coronary interventions (including percutaneous and surgical procedures) and medical therapy are known to significantly vary according to gender. However, investigators of the ISCHEMIA trial sought to determine if these gender differences were also apparent in the ISCHEMIA trial data. As a result, this study aimed to fill this gap by analyzing ISCHEMIA outcomes according to participant sex.

Recently published in EuroIntervention, additional analysis from the ISCHEMIA trial evaluated three main aspects: first, the association between participant sex and the likelihood of undergoing revascularization among those randomized to the INV arm; second, the risk of the ISCHEMIA primary composite outcome (cardiovascular death, myocardial infarction [MI], or rehospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) by participant sex; and third, the contribution of individual primary outcome components to the composite outcome by participant sex.

Results indicated that among the 5,179 randomized participants, 1,168 (22.6%) were women. Female sex was independently associated with a lower likelihood of revascularization when assigned to the INV arm. Despite this difference, the effect of INV versus CON strategies on the primary composite outcome did not significantly vary between sexes. However, there was a notable gender disparity in the contribution of procedural MI to the primary outcome, with women experiencing significantly lower rates compared to men.

The authors concluded that women assigned to the INV arm were less likely to undergo revascularization compared to men. While the overall effect of INV versus CON strategy was consistent across sexes, women exhibited significantly lower procedural MI rates, highlighting potential gender-based disparities in treatment outcomes for coronary artery disease. The authors further emphasized that the consistent trend of women having a lower likelihood than men to be referred for coronary revascularization aligns with findings from extensive registry studies. However, it remains unclear whether these lower referral rates for women stem from physician bias, disparities in baseline clinical status, or differences in the extent of coronary artery disease.

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Original article: Gaudino M et al. EuroIntervention. 2024 Mar 5:EIJ-D-24-00011. 

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