Impact of Sex on 3-Year Outcome After Percutaneous Coronary Intervention Using Bare-Metal and Drug-Eluting Stents in Previously Untreated Coronary Artery DiseaseInsights From the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) Registries
Yoshinobu Onuma, MD,
Neville Kukreja, MA,
Joost Daemen, MD,
Hector M. Garcia-Garcia, MD, MSc,
Nieves Gonzalo, MD,
Jin Ming Cheng, MSc,
Piet Hein van Twisk, MSc,
Ron van Domburg, MD, PhD,
Patrick W. Serruys, MD, PhD* on behalf of the Interventional Cardiologists of Thoraxcenter
Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
 |
Abstract
|
|---|
Objectives: We investigated the impact of sex on outcomes after percutaneous coronary intervention (PCI) with drug-eluting stent (DES).
Background: Women have a higher risk of adverse outcomes after PCI than do men. However, long-term outcomes of women after contemporary PCI with DES have not been fully investigated.
Methods: We performed a retrospective cohort study of 4,936 consecutive patients (28.2% women) who underwent PCIs between 2000 and 2004, before and after introduction of DES (bare-metal stent [BMS] group: n = 2,131, DES group: n = 2,805), to assess the impact of sex on long-term PCI outcomes and to compare outcome after PCI of women between the DES and BMS eras.
Results: Compared with men, women undergoing PCIs were 5 years older and more frequently have comorbidities such as diabetes mellitus and hypertension. In patients treated throughout the BMS and DES eras, there were no differences by sex for risk of all-cause death, myocardial infarction, or target vessel revascularization 3 years after procedure. The procedural complexity was higher in the DES era, nevertheless, risk for target vessel revascularization and major adverse cardiac event at 3 years were significantly lower in women treated with DES than in women treated with BMS (adjusted hazard ratio [HR] for target vessel revascularization: 0.52 [95% confidence interval (CI): 0.36 to 0.75], adjusted HR for major adverse cardiac event: 0.63 [95% CI: 0.48 to 0.83]).
Conclusions: Although women had worse baseline characteristics, no differences in 3-year outcomes were observed between men and women. Compared with BMS use, DES use has decreased revascularization rate equally in women and men.
Key Words: percutaneous coronary intervention • bare-metal stent • drug-eluting stent • major adverse cardiac event • myocardial infarction • target vessel revascularization • target lesion revascularization
|
Abbreviations and Acronyms
| | BMS = bare-metal stent(s) | | DES = drug-eluting stent(s) | | MACE = major adverse cardiac event | | MI = myocardial infarction | | PCI = percutaneous coronary intervention | | PES = paclitaxel-eluting stent(s) | | SES = sirolimus-eluting stent(s) | | TIMI = Thrombolysis In Myocardial Infarction | | TVR = target vessel revascularization |
|
Coronary heart disease remains the leading cause of death among men and women in developed countries (1), and in Europe, around 25% of coronary revascularization is performed on women (2). In the early balloon angioplasty era, several studies found that female sex was an independent predictor of in-hospital mortality and that compared with men, women had lower rates of angiographic success, higher incidence of procedural complications and in-hospital death, and worse long-term outcomes after percutaneous coronary intervention (PCI) (3–5). In the bare-metal stent (BMS) era, sex-based differences in outcomes have decreased in patients undergoing PCI (6,7). In a large prospective registry study of 4,374 patients treated with BMS, women had lower rates of restenosis at 6-month angiographic follow-up compared with men, and women less frequently required target vessel revascularization (TVR) at 1 year: female sex was an independent predictor of freedom from restenosis (8). Furthermore, a recent study (9) performed in patients treated with BMS demonstrated that female sex conferred a long-term survival advantage after PCI despite the presence of higher risk characteristics.
Clinical practice of PCI has changed since the introduction of the drug-eluting stent (DES) with a significantly lower rate of restenosis compared with BMS use (10). There is currently a paucity of published data available on the comparison of sex after PCI using DES. Pivotal trials of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have included only a small number of women and were limited to patients with elective PCI and selective angiographic characteristics. In these low-risk populations, sex was not independently associated with adverse outcomes (11,12). Recently, using the National Heart, Lung, and Blood Institute (NHLBI) dynamic registry including high-risk patients, Abbott et al. (13) reported that adjusted 1-year outcomes in BMS and DES were independent of sex. However, the impact of sex on long-term outcome in unselected patients after PCI has not yet been fully investigated. Therefore, we performed an analysis using the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) registries' data to assess the impact of sex on long-term PCI outcomes and to compare outcome after PCI of women between the DES and BMS eras.
|
Methods
|
|---|
Study design and patient population.
Between January 1, 2000, and December 31, 2004, 5,358 patients underwent PCI in our institution using BMS, SES, or PES. Initially, all patients were treated with BMS, but on April 16, 2002, our institution adopted the use of SES (Cypher, Cordis, Warren, New Jersey) as the default strategy for all coronary interventions, as part of the RESEARCH registry (14). On February 16, 2003, SES was replaced by PES (TAXUS, Boston Scientific, Natick, Massachusetts) as the default stent, as part of the T-SEARCH registry (15). The exclusion criteria were PCI for a lesion involving a previously implanted stent (n = 287) or patients receiving only BMS (n = 135) in the DES era, because of the unavailability of the adequate size of DES (Fig. 1). In total, 4,936 patients were included in the current study. We defined the BMS group as patients treated in a period before introduction of SES (January 2000 to April 2002, n = 2,131) and the DES group as those treated after introduction of SES (April 2002 to December 2004, n = 2,805).
View larger version (19K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1 A Flowchart of Patient Selection
Out of 5,358 patients who underwent percutaneous intervention in a single center from 2000 to 2004, 4,936 patients were included in this analysis after exclusion of 422 patients. BMS = bare-metal stent(s); DES = drug-eluting stent(s).
|
|
Procedures and medications.
All procedures were performed according to standard clinical guidelines at the time (14,15). During this period of study, primary PCI was the default strategy for all patients with ST-segment elevation myocardial infarction presenting within 6 h of symptom onset. The patients are transferred either directly by the ambulance service or by local emergency departments directly to our catheter laboratory. Angiographic success was defined as a residual stenosis  30% by visual analysis in the presence of Thrombolysis In Myocardial Infarction (TIMI) flow grade 3. All patients were pre-treated with 300 mg of clopidogrel. At least 1-month of clopidogrel treatment (75 mg/day) was recommended for patients treated with BMS. Clopidogrel was prescribed for  3 or 6 months for patients with SES depending of the complexity of the procedure and for 6 months for patients treated with PES. Life-long aspirin therapy was recommended in all patients.
End point definitions and clinical follow-up.
The primary end point was major adverse cardiac event (MACE), defined as all-cause death, nonfatal myocardial infarction (MI) irrespective of the stented vessel or TVR. Secondary end points included all-cause mortality, any MI, TVR, target lesion revascularization, definite stent thrombosis, and the composites of all-cause death or nonfatal MI. Myocardial infarction was diagnosed by a rise in creatine kinase-MB >3 times the upper limit of normal (16). Target vessel revascularization was defined as a repeat revascularization of a lesion in the same epicardial vessel treated in the index procedure (17). Target lesion revascularization was defined as a repeat intervention in the stent or in the 5-mm segments proximal or distal to the stent. Hypercholesterolemia was defined as a fasting serum cholesterol level >5.5 mmol/l or use of lipid-lowering therapy at the time of the procedure. Hypertension was defined as blood pressure >140/90 mm Hg or the use of antihypertensive medications. Stent thrombosis was defined as angiographically defined thrombosis with TIMI flow grade 0 or 1 or the presence of a flow-limiting thrombus, accompanied by acute symptoms, irrespective of whether there had been an intervening reintervention (18). The timing of stent thrombosis was categorized as early (within 30 days after implantation), late (between 30 days and 1 year after implantation), or very late (more than 1 year after implantation) (19).
Follow-up data.
Survival data for all patients were obtained from municipal civil registries. A questionnaire was subsequently sent to all living patients with specific questions on rehospitalization and MACE year by year. As the principal regional cardiac referral center, repeat revascularizations, either percutaneous or surgical, are normally performed at our institution and recorded prospectively in our database. For patients who suffered an adverse event at another center, medical records or discharge letters from the other institutions were systematically reviewed. General practitioners and referring physicians were contacted for additional information if necessary.
Statistical analysis.
Continuous variables are presented as mean ± SD, whereas categorical variables are expressed as percentages. Statistical comparison was made between women and men and stratified by stent type (BMS and DES). Comparisons among the groups were performed by Fisher exact test for categorical variables. All statistical tests were 2-tailed, and a p value of <0.05 was considered statistically significant. The incidence of events over time was studied with the Kaplan-Meier method, and log-rank tests were applied to evaluate the difference. Patients lost to follow-up were considered at risk until the date of last contact, at which point they were censored. Cox proportional hazard methods were used to estimate unadjusted and adjusted risk ratios of clinical events at each year in relation to sex and stent type. Models were adjusted for age, cardiogenic shock, presentation with acute MI or unstable angina, hypertension, current smoking, dyslipidemia, diabetes, multivessel disease, family history of coronary artery disease, previous PCI, previous MI, previous coronary artery bypass graft, treatment of chronic total occlusion, bifurcation, bypass graft or left main lesion, American Heart Association classification B2 or C, total stented length, number of implanted stents, and recommended duration of clopidogrel. Cox proportional-hazards models adjusted with the same variables as well as stent type also were used to assess relative risks of 3-year MACE in female sex compared with male sex among patient subgroups. Statistical analysis was performed with SPSS version 12.0 for windows (SPSS Inc., Chicago, Illinois).
|
Results
|
|---|
Among 4,936 patients included in the analysis, 3,542 (71.8%) were men and 1,394 (28.2%) were women. A total of 2,131 patients received BMS (596 women and 1,535 men), and 2,805 patients were treated with DES (798 women and 2,007 men). Baseline and procedural characteristics stratified by sex and stent type are depicted in Table 1. Among patients treated with BMS, women were on average approximately 5 years older; more often had diabetes, hypertension, current smoking habit, and left main disease, and less often had previous MI. Women more often underwent PCI for unstable angina but less often for an acute MI. Recommended clopidogrel duration was longer than in men, but glycoprotein IIb/IIIa were less frequently used in women.
In demographic and procedural characteristics, differences among men and women receiving DES were similar to differences observed in patients with BMS. However, in the DES era, the rates of left main disease and duration of clopidogrel administration were comparable between men and women. Furthermore, women have lower rates of multivessel disease, bypass graft disease, and smaller diameter of stent used.
Clinical follow-up was available in 4,936 patients (98.9%: male 98.8%, female 99.3%) with a median duration of follow-up of 1,520 days. Cumulative incidences of clinical end points up to 3 years are presented in Table 2. In patients with BMS and DES, there were no differences by sex for rates of all-cause death, MI, TVR, stent thrombosis, and MACE throughout the 3 years after procedure.
DES versus BMS in women and men.
Among the subgroups of women and men, treatment for acute MI was more frequent in patients with DES than BMS. Risk factors such as hypertension, family history, and current smoking were more frequently observed in patients with DES. The procedural complexity was higher in DES, illustrated by an increase in the treatment of type C lesions and bifurcations. In DES patients, when compared with BMS patients, total stented length and number of stents increased, but the average stent diameter decreased. Rates for TVR and MACE at any time point were significantly lower in women and men treated with DES than in patients of both sexes treated with BMS (Table 2, Fig. 2). At the 3-year follow-up, definite stent thrombosis was higher in men with DES than in men treated with BMS (2.6% vs. 1.5%, log-rank: p = 0.04), whereas it was similar in women treated with DES or BMS (2.0% vs. 1.8%, p = 0.52).
View larger version (17K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2 Kaplan-Meier Curve of MACE up to 3 Years After Index Procedure Among 4 Groups
Major adverse cardiac event (MACE) rates were significantly lower in women (solid red line) and men (dotted red line) treated with DES than in patients of both sexes treated with BMS (solid black line for women, dotted black line for men). Abbreviations as in Figure 1.
|
|
Multivariate analyses.
Unadjusted and adjusted models stratified by stent type showed that female sex did not confer a benefit or risk for any adverse events (Table 3), whereas the use of DES was associated with a lower risk of TVR or MACE in men and women at 1-, 2-, and 3-year follow-ups. At 3 years, the risk of definite stent thrombosis was higher in men with DES versus BMS in univariate analysis (hazard ratio [HR]: 1.7 [95% confidence interval (CI): 1.03 to 2.81]); this difference was not significant in the adjusted model (adjusted HR: 1.83 [95% CI: 0.93 to 3.59]).
View this table:
[in this window]
[in a new window]
|
Table 3 Unadjusted and Adjusted HR for Sex (Women vs. Men) in Each Stent Type or for Stent Type (DES vs. BMS) in Each Sex
|
|
Figure 3
represents the results of subgroup multivariate analysis of the association between sex and the risk of MACE at 3-year follow-up in patients treated with DES. Female sex did not confer a benefit or risk for MACE in any groups except for the subpopulation presenting with acute MI (adjusted HR women vs. men: 1.37 [95% CI: 1.02 to 1.85]).
View larger version (22K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3 Adjusted Hazard Ratio of Women Versus Men on MACE at Year 3 in Subgroups
Female sex was not associated with differential MACE risk from male sex in any groups except for those presenting with acute myocardial infarction (adjusted HR women vs. men: 1.37 [95% CI: 1.02 to 1.85]). CI = confidence interval; HR = hazard ratio; other abbreviations as in Figure 2.
|
|
|
Discussion
|
|---|
The main findings of the current analysis from the T-SEARCH and RESEARCH registries with respect to sex are as follows: 1) DES use was associated with lower rates of TVR or MACE in both sexes; 2) after stratification for stent type, all clinical end points at any time points up to 3 years were similar between both sexes; and 3) in the subpopulation of patients presenting with acute MI, the risk of MACE at 3 years was higher in women than in men.
Only few data are available regarding sex differences in the DES era. In the TAXUS-IV–2 Year Data (TAXUS-IV) trial, they found that women had more comorbidities and an overall higher rate of repeat PCI than men did (7.6% vs. 3.2%, p = 0.03), but the restenosis rates and late loss were similar by sex in the DES arm of the study (11). In a pooled analysis of 1,748 patients from 4 randomized SES versus BMS trials, Solinas et al. (12) reported that despite less favorable baseline characteristics in women compared with men, at 1 year, the clinical benefits of SES were independent of sex, with reductions of binary restenosis both in women (6.3% vs. 43.8%) and in men (6.4% vs. 35.6%). Recently, using data from NHLBI dynamic registry, including high-risk patients, Abbott et al. (13) reported that patients with DES had a lower rate of repeat PCI in both sexes (14.1% in women vs. 9.5%, p = 0.02; 12.0% in men vs. 8.8%, p = 0.02) at 1 year. Our findings not only confirm the results of previous studies but also suggest that this superiority of DES to lower revascularization is maintained in both sexes up to 3 years after procedure.
In our analysis, women treated with DES had worse baseline demographics, including older age and higher prevalence of comorbidities, especially diabetes, which is associated with higher rates of restenosis. However, clinical outcomes were independent of sex with the benefit of DES over BMS being almost identical throughout the 3-year clinical follow-up. This is in contrast to previous PCI series that have reported an association between sex and clinical and angiographic restenosis rates (8,20), but it concurs with the data from a recent series on 3,223 patients, in which 1-year clinically driven revascularization was similar for both sexes (13).
Our subgroup analysis suggests that women presenting with acute MI still have worse outcomes than men do. Because there were substantially fewer females than males (19.5% vs. 29.1%) in this subset, it is plausible that this inequality in proportions could be responsible for the failure to reach statistical significance for the outcomes between sexes and that even matching would have worsened the outcomes of the female cohort. In general, unadjusted comparisons of mortality after acute MI have generally indicated that women have a poorer outcome than men (21,22) and have less favorable short-term outcomes after revascularization procedures (23). In our institution, primary PCI was the default strategy for all patients with acute MI presenting within 6 h of symptom onset. Therefore, our results suggest that despite the use of DES with contemporary PCI techniques, the outcome of women with ST-segment elevation myocardial infarction still needs to be improved. In addition to anatomical differences, the basic biological differences in response to acute MI between men and women have also been suggested (24). Further investigation in this high-risk population is warranted.
Study limitations.
The current study suffers from the inherent limitations of a nonrandomized trial. There were significant differences between BMS and DES and between both sexes in terms of baseline demographics. To compensate for these differences, we have performed adjustments employing multivariate analyses, although we cannot adjust confounding factors such as changes in practice during this period using various material, different guidelines, or operator's experiences. Nevertheless, these unselected patients represent real-world practice, whereas patients enrolled in clinical trials are carefully selected. In addition, we only investigated angiographically documented stent thrombosis, using a definition consistent with previous reports on stent thrombosis either after DES or BMS implantation. The latter may have led to an underestimation of the actual incidence of stent thrombosis, particularly, in patients suffering from sudden cardiac death or silent stent occlusion.
|
Acknowledgments
|
|---|
The authors would like to acknowledge the senior cardiologists involved in the PCI procedures: Drs. E. McFadden, P. J. de Feyter, P. P. T. de Jaegere, S. H. Hofma, E. Regar, G. Sianos, P. C. Smits, M. J. van der Ent, W. J. van der Giessen, C. A. van Mieghem, R. J. van Geuns, and H. Duckers.
* Reprint requests and correspondence: Prof. Patrick W. Serruys, Thoraxcenter, Ba-583, 's Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands (Email: p.w.j.c.serruys{at}erasmusmc.nl).
Manuscript received February 9, 2009;
accepted March 4, 2009.
|
REFERENCES
|
|---|
- Rosamond W, Flegal K, Friday G, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation 2007;115:e69-e171.[Free Full Text]
- Lenzen MJ, Boersma E, Bertrand ME, et al. European Society of Cardiology Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization Eur Heart J 2005;26:1169-1179.[Abstract/Free Full Text]
- Malenka DJ, O'Connor GT, Quinton H, et al. Differences in outcomes between women and men associated with percutaneous transluminal coronary angioplasty. A regional prospective study of 13,061 procedures. Northern New England Cardiovascular Disease Study Group. Circulation 1996;94:II99-II104.[Medline]
- Cowley MJ, Mullin SM, Kelsey SF, et al. Sex differences in early and long-term results of coronary angioplasty in the NHLBI PTCA Registry Circulation 1985;71:90-97.[Abstract/Free Full Text]
- Kelsey SF, James M, Holubkov AL, Holubkov R, Cowley MJ, Detre KM. Results of percutaneous transluminal coronary angioplasty in women. 1985–1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry. Circulation 1993;87:720-727.[Abstract/Free Full Text]
- Jacobs AK, Johnston JM, Haviland A, et al. Improved outcomes for women undergoing contemporary percutaneous coronary intervention: a report from the National Heart, Lung, and Blood Institute Dynamic registry J Am Coll Cardiol 2002;39:1608-1614.[Abstract/Free Full Text]
- Peterson ED, Lansky AJ, Kramer J, Anstrom K, Lanzilotta MJ. Effect of gender on the outcomes of contemporary percutaneous coronary intervention Am J Cardiol 2001;88:359-364.[CrossRef][Web of Science][Medline]
- Mehilli J, Kastrati A, Bollwein H, et al. Gender and restenosis after coronary artery stenting Eur Heart J 2003;24:1523-1530.[Abstract/Free Full Text]
- Berger JS, Sanborn TA, Sherman W, Brown DL. Influence of sex on in-hospital outcomes and long-term survival after contemporary percutaneous coronary intervention Am Heart J 2006;151:1026-1031.[CrossRef][Web of Science][Medline]
- Serruys PW, Kutryk MJ, Ong AT. Coronary-artery stents N Engl J Med 2006;354:483-495.[CrossRef][Web of Science][Medline]
- Lansky AJ, Costa RA, Mooney M, et al. Gender-based outcomes after paclitaxel-eluting stent implantation in patients with coronary artery disease J Am Coll Cardiol 2005;45:1180-1185.[Abstract/Free Full Text]
- Solinas E, Nikolsky E, Lansky AJ, et al. Gender-specific outcomes after sirolimus-eluting stent implantation J Am Coll Cardiol 2007;50:2111-2116.[Abstract/Free Full Text]
- Abbott JD, Vlachos HA, Selzer F, et al. National Heart, Lung, and Blood Institute Dynamic Registry Gender-based outcomes in percutaneous coronary intervention with drug-eluting stents (from the National Heart, Lung, and Blood Institute Dynamic Registry) Am J Cardiol 2007;99:626-631.[CrossRef][Web of Science][Medline]
- Lemos PA, Serruys PW, van Domburg RT, et al. Unrestricted utilization of sirolimus-eluting stents compared with conventional bare stent implantation in the "real world": the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry Circulation 2004;109:190-195.[Abstract/Free Full Text]
- Ong AT, Serruys PW, Aoki J, et al. The unrestricted use of paclitaxel- versus sirolimus-eluting stents for coronary artery disease in an unselected population: one-year results of the Taxus-Stent Evaluated at Rotterdam Cardiology Hospital (T-SEARCH) registry J Am Coll Cardiol 2005;45:1135-1141.[Abstract/Free Full Text]
- Smith Jr. SC, Feldman TE, Hirshfeld Jr. JW, et al. American College of Cardiology/American Heart Association Task Force on Practice GuidelinesAmerican College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) Circulation 2006;113:156-175.[Free Full Text]
- Lemos PA, Lee CH, Degertekin M, et al. Early outcome after sirolimus-eluting stent implantation in patients with acute coronary syndromes: insights from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry J Am Coll Cardiol 2003;41:2093-2099.[Abstract/Free Full Text]
- Ong AT, Hoye A, Aoki J, et al. Thirty-day incidence and six-month clinical outcome of thrombotic stent occlusion after bare-metal, sirolimus, or paclitaxel stent implantation J Am Coll Cardiol 2005;45:947-953.[Abstract/Free Full Text]
- Cutlip DE, Windecker S, Mehran R, et al. Clinical end points in coronary stent trials: a case for standardized definitions Circulation 2007;115:2344-2351.[Abstract/Free Full Text]
- Kishi K, Hiasa Y, Suzuki N, et al. Predictors of recurrent restenosis after coronary stenting: an analysis of 197 patients J Invasive Cardiol 2002;14:187-191.[Medline]
- Vaccarino V, Abramson JL, Veledar E, Weintraub WS. Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women Circulation 2002;105:1176-1181.[Abstract/Free Full Text]
- Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med 1999;341:217-225.[CrossRef][Web of Science][Medline]
- Antoniucci D, Valenti R, Moschi G, et al. Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction Am J Cardiol 2001;87:289-293.[CrossRef][Web of Science][Medline]
- Alter DA, Naylor CD, Austin PC, Tu JV. Biology or bias: practice patterns and long-term outcomes for men and women with acute myocardial infarction J Am Coll Cardiol 2002;39:1909-1916.[Abstract/Free Full Text]
Related Article
-
The Efficacy of Drug-Eluting Stents in Women: A Window of Opportunity
- Alice K. Jacobs
J. Am. Coll. Cardiol. Intv. 2009 2: 611-613.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
G. W. Mikhail, R. T. Gerber, D. A. Cox, S. G. Ellis, J. M. Lasala, J. A. Ormiston, G. W. Stone, M. A. Turco, A. A. Joshi, D. S. Baim, et al.
Influence of Sex on Long-Term Outcomes After Percutaneous Coronary Intervention With the Paclitaxel-Eluting Coronary Stent: Results of the "TAXUS Woman" Analysis
J. Am. Coll. Cardiol. Intv.,
December 1, 2010;
3(12):
1250 - 1259.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. K. Jacobs
The Efficacy of Drug-Eluting Stents in Women: A Window of Opportunity
J. Am. Coll. Cardiol. Intv.,
July 1, 2009;
2(7):
611 - 613.
[Full Text]
[PDF]
|
|
|
|
Top
Abstract
Methods