Has the gender gap in percutaneous coronary intervention‐related mortality narrowed?

The impact of female gender on outcomes following percutaneous coronary intervention (PCI) remains controversial. In contrast to early studies which found female gender to be an independent predictor of mortality post-PCI, later studies, after adjusting for potential confounders, demonstrated that rates of mortality after PCI were similar in both genders [1]. It is believed that the apparent increase in mortality reflected by the unadjusted data in some studies more accurately reflected the higher rates of comorbidities in women. Regardless, it seems there was an overall improvement in clinical outcomes for women between the initial balloon angioplasty era and the then newer bare metal stent (BMS) era. Later, a handful of studies, including observations from randomized trials, compared the more modern drug eluting stent (DES) to the earlier BMS era with respect to gender outcomes. The results are mixed, though recent data suggest that adjusted mortality rates are no different between men and women in a population of unrestricted DES use [2]. For the most part, real-world data support the notion that female gender by itself is no longer predictive of worse outcomes in the current DES era, although applicability to a group of ethnically diverse women remains unknown. In this current issue of Catheterization and Cardiovascular Interventions, Kovacic et al. expand on this subject with observational data from a large ethnically diverse group of women to further delineate whether female gender itself portends increased risk following PCI in this current DES era. Similar to previous studies, the unadjusted analysis showed higher rates of mortality for women who were frequently older, had more diabetes, hypertension, peripheral vascular disease, and renal insufficiency—all markers of adverse cardiovascular outcomes. Following multivariable analysis however, female gender itself failed to confer higher mortality risk post-PCI. Further propensity matched analysis confirmed this finding [3]. Unfortunately, the study did not collect data on bleeding events, a complication that disproportionately affects more women than men. The good news in all of this is women, who account for a significant number of PCIs performed annually in the United States, should feel assured that overall mortality rates have consistently declined with time, and that they can now undergo PCI without fear of risk in excess of that experienced by their male counterparts. Many factors account for this improvement. First, technological advances in interventional equipment have resulted in better technical outcomes. Second, greater use of evidence-based therapies has been associated with a reduction of events post-PCI and reduction of cardiovascular mortality long-term. Third, better understanding of peri-procedure anticoagulation with increased use of bivalirudin, and less frequent use of glycoprotein IIb/IIIa inhibitors have resulted in a reduction of bleeding events [4], events which had already been shown to increase mortality. Furthermore, the increasing adoption of transradial access for PCI has been associated with reduction in bleeding and access site complications. That said, transradial catheterization remains underused in the US and this represents another opportunity for further reduction in adverse events post-PCI in both genders. The ongoing SAFE-PCI for Women trial (NCT 01406236) is examining this relevant and timely question. Lastly, one should find it bothersome that women have consistently had a greater burden of comorbid conditions in many of these studies, a finding which has allowed female gender to remain associated with adverse outcomes following PCI. This may partially be related to biological differences between genders and referral