Sex Differences in Revascularization, Treatment Goals, and Outcomes of Patients With Chronic Coronary Disease: Insights From the ISCHEMIA Trial
Harmony R. Reynolds, Derek D. Cyr, C. Noel Bairey Merz, Leslee J. Shaw, Bernard Chaitman, William E. Boden, Karen P. Alexander, Yves Rosenberg, Sripal Bangalore, Gregg W. Stone, Claes Held, John A. Spertus, Kaatje Goetschalckx, O.L. Bockeria, Jonathan Newman, Jeffrey S. Berger, Ahmed Elghamaz, Renato D. Lópes, James K. Min, Daniel S. Berman, Michael H. Picard, Raymond Y. Kwong, Robert A. Harrington, Boban Thomas, Sean M. O’Brien, David J. Maron, Judith S. Hochman, Kreton Mavromatis, Jason Linefsky, Todd Q. Miller, Subhash Banerjee, Harmony R. Reynolds, Jonathan Newman, Sripal Bangalore, Robert Donnino, Lawrence M. Phillips, Muhamed Sarić, Khaled Abdul‐Nour, Peter H. Stone, James J. Jang, Gennie Yee, Steven Weitz, Suzanne V. Arnold, James H. O’Keefe, Michael D. Shapiro, Mohammad El‐Hajjar, Mandeep S. Sidhu, Steven Fein, Mikhail Torosoff, Radmila Lyubarova, Sulagna Mookherjee, Krzysztof Drzymalski, Edward O. McFalls, Santiago García, Stefan Bertog, Rizwan A. Siddiqui, Areef Ishani, Ronnell A. Hansen, Michel G. Khouri, Jonathan Goldberg, Richard Goldweit, Ronny Cohen, Brooks Mirrer, Victor J. Navarro, David E. Winchester, Marvin W. Kronenberg, Philip Rogal, Christopher McFarren, John F. Heitner, Ira Dauber, Charles R. Cannan, Sriram Sudarshan, Puja K. Mehta, Michael McDaniel, Stamatios Lerakis, Arshed A. Quyyumi, Nanette K. Wenger, Chester M. Hedgepeth, Heather Hurlburt, Alan Rosen, Zakir Sahul, David T. Booth, Steve Leung, Ahmed Abdel‐Latif, Hassan Reda, Khaled M. Ziada, Sampoornima Setty, Rajat S. Barua, Fadi G. Hage, Christiano Caldeira, James E. Davies, Massoud A. Leesar, Jaekyeong Heo, Amy Iskandrian, Firas Al Solaiman, Satinder P. Singh, Khaled Dajani, Mohammad El‐Hajjar, Paul Der Mesropian, Joseph Sacco
Abstract
Background Women with chronic coronary disease are generally older than men and have more comorbidities but less atherosclerosis. We explored sex differences in revascularization, guideline‐directed medical therapy, and outcomes among patients with chronic coronary disease with ischemia on stress testing, with and without invasive management. Methods and Results The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized patients with moderate or severe ischemia to invasive management with angiography, revascularization, and guideline‐directed medical therapy, or initial conservative management with guideline‐directed medical therapy alone. We evaluated the primary outcome (cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) and other end points, by sex, in 1168 (22.6%) women and 4011 (77.4%) men. Invasive group catheterization rates were similar, with less revascularization among women (73.4% of invasive‐assigned women revascularized versus 81.2% of invasive‐assigned men; P <0.001). Women had less coronary artery disease: multivessel in 60.0% of invasive‐assigned women and 74.8% of invasive‐assigned men, and no ≥50% stenosis in 12.3% versus 4.5% ( P <0.001). In the conservative group, 4‐year catheterization rates were 26.3% of women versus 25.6% of men ( P =0.72). Guideline‐directed medical therapy use was lower among women with fewer risk factor goals attained. There were no sex differences in the primary outcome (adjusted hazard ratio [HR] for women versus men, 0.93 [95% CI, 0.77–1.13]; P =0.47) or the major secondary outcome of cardiovascular death/myocardial infarction (adjusted HR, 0.93 [95% CI, 0.76–1.14]; P =0.49), with no significant sex‐by‐treatment‐group interactions. Conclusions Women had less extensive coronary artery disease and, therefore, lower revascularization rates in the invasive group. Despite lower risk factor goal attainment, women with chronic coronary disease experienced similar risk‐adjusted outcomes to men in the ISCHEMIA trial. Registration URL: http://wwwclinicaltrials.gov . Unique identifier: NCT01471522.