Gender Differences in Outcome After Coronary Revascularization

  • Kyohei Yamaji
  • Takeshi KimuraEmail author


Women were associated with greater short-term mortality following coronary revascularization, mainly driven by older age and greater prevalence of comorbidities. Long-term outcomes after coronary revascularization are similar between men and women, or even better in women. Intracoronary imaging studies showed fewer “high-risk” plaques in women as compared with men. While there was a significant difference in coronary flow reserve between men and women, the importance of this observation remains to be determined. There were significant sex difference in diagnostic testing and managements, while it remains unclear whether there are sex-specific differences in the clinical phenotype of coronary artery disease, or in sex-specific bias of diagnostic testing, or both. In patients who undergo percutaneous coronary intervention, newer generation drug-eluting stents are recommended for use in both men and women based on the currently available evidences. In conclusion, sex difference in coronary disease burden, coronary physiology, response to diagnostic testing, and clinical management may play an important role in the observed difference in clinical outcomes between men and women. Further studies are needed to elucidate sex differences following coronary revascularization.


Coronary revascularization Percutaneous coronary intervention Coronary artery bypass grafting Coronary physiology Drug-eluting stent Coronary artery disease 


  1. 1.
    Jneid H, Fonarow GC, Cannon CP, et al. Sex differences in medical care and early death after acute myocardial infarction. Circulation. 2008;118:2803–10.CrossRefPubMedCentralPubMedGoogle Scholar
  2. 2.
    Heer T, Hochadel M, Schmidt K, et al. Sex differences in percutaneous coronary intervention—insights from the coronary angiography and PCI registry of the German. J Am Heart Assoc. 2017;6(3).
  3. 3.
    Lempereur M, Magne J, Cornelis K, et al. Impact of gender difference in hospital outcomes following percutaneous coronary intervention. Results of the Belgian Working Group on Interventional Cardiology (BWGIC) registry. EuroIntervention. 2016;12(2):e216–23.CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Shahian DM, O’Brien SM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1—coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88:S2–22.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Nashef SAM, Roques F, Sharples LD, et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41:734–45.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Khera S, Kolte D, Gupta T, et al. Temporal trends and sex differences in revascularization and outcomes of ST-segment elevation myocardial infarction in younger adults in the United States. J Am Coll Cardiol. 2015;66:1961–72.CrossRefPubMedGoogle Scholar
  7. 7.
    Alam M, Lee V-V, Elayda MA, et al. Association of gender with morbidity and mortality after isolated coronary artery bypass grafting. A propensity score matched analysis. Int J Cardiol. 2013;167:180–4.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Filardo G, Hamman BL, Pollock BD, et al. Excess short-term mortality in women after isolated coronary artery bypass graft surgery. Open Heart. 2016;3:e000386.CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Yamaji K, Shiomi H, Morimoto T, et al. Influence of sex on long-term outcomes after implantation of bare-metal stent: a multicenter report from the Coronary Revascularization Demonstrating Outcome Study-Kyoto (CREDO-Kyoto) Registry Cohort-1. Circulation. 2015;132:2323–33.CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Nicolini F, Vezzani A, Fortuna D, et al. Gender differences in outcomes following isolated coronary artery bypass grafting: long-term results. J Cardiothorac Surg. 2016;11:144.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Falk E. Plaque rupture with severe pre-existing stenosis precipitating coronary thrombosis. Characteristics of coronary atherosclerotic plaques underlying fatal occlusive thrombi. Br Heart J. 1983;50:127–34.CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Adams MR, Kaplan JR, Manuck SB, et al. Inhibition of coronary artery atherosclerosis by 17-beta estradiol in ovariectomized monkeys. Lack of an effect of added progesterone. Arteriosclerosis. 1990;10:1051–7.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Burke AP, Farb A, Malcom GT, Liang Y, Smialek J, Virmani R. Effect of risk factors on the mechanism of acute thrombosis and sudden coronary death in women. Circulation. 1998;97:2110–6.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Herity NA, Lo S, Lee DP, et al. Effect of a change in gender on coronary arterial size: a longitudinal intravascular ultrasound study in transplanted hearts. J Am Coll Cardiol. 2003;41:1539–46.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Ruiz-García J, Lerman A, Weisz G, et al. Age- and gender-related changes in plaque composition in patients with acute coronary syndrome: the PROSPECT study. EuroIntervention. 2012;8:929–38.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Wang L, Mintz GS, Witzenbichler B, et al. Differences in underlying culprit lesion morphology between men and women: an IVUS analysis from the ADAPT-DES study. JACC Cardiovasc Imaging. 2016;9:498–9.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Bharadwaj AS, Vengrenyuk Y, Yoshimura T, et al. Multimodality intravascular imaging to evaluate sex differences in plaque morphology in stable CAD. JACC Cardiovasc Imaging. 2016;9:400–7.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Ten Haaf ME, Rijndertse M, Cheng JM, et al. Sex differences in plaque characteristics by intravascular imaging in patients with coronary artery disease. EuroIntervention. 2017;13:320–8.CrossRefPubMedCentralPubMedGoogle Scholar
  19. 19.
    Han SH, Bae JH, Holmes DR, et al. Sex differences in atheroma burden and endothelial function in patients with early coronary atherosclerosis. Eur Heart J. 2008;29:1359–69.CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Tonino PAL, De Bruyne B, Pijls NHJ, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360:213–24.CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Kim H-S, Tonino PAL, De Bruyne B, et al. The impact of sex differences on fractional flow reserve–guided percutaneous coronary intervention. JACC Cardiovasc Interv. 2012;5:1037–42.CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Murthy VL, Naya M, Taqueti VR, et al. Effects of sex on coronary microvascular dysfunction and cardiac outcomes. Circulation. 2014;129:2518–27.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Kobayashi Y, Fearon WF, Honda Y, et al. Effect of sex differences on invasive measures of coronary microvascular dysfunction in patients with angina in the absence of obstructive coronary artery disease. JACC Cardiovasc Interv. 2015;8:1433–41.CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Pagidipati NJ, Hemal K, Coles A, et al. Sex differences in functional and CT angiography testing in patients with suspected coronary artery disease. J Am Coll Cardiol. 2016;67:2607–16.CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Omland T, de Lemos JA, Sabatine MS, et al. A sensitive cardiac troponin T assay in stable coronary artery disease. N Engl J Med. 2009;361:2538–47.CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Harada Y, Michel J, Koenig W, et al. Prognostic value of cardiac troponin T and sex in patients undergoing elective percutaneous coronary intervention. J Am Heart Assoc. 2016;5:1–9.CrossRefGoogle Scholar
  27. 27.
    Hemal K, Pagidipati NJ, Coles A, et al. Sex differences in demographics, risk factors, presentation, and noninvasive testing in stable outpatients with suspected coronary artery disease: insights from the PROMISE trial. JACC Cardiovasc Imaging. 2016;9:337–46.CrossRefPubMedCentralPubMedGoogle Scholar
  28. 28.
    Ferrari R, Abergel H, Ford I, et al. Gender- and age-related differences in clinical presentation and management of outpatients with stable coronary artery disease. Int J Cardiol. 2013;167:2938–43.CrossRefPubMedCentralPubMedGoogle Scholar
  29. 29.
    Solinas E, Nikolsky E, Lansky AJ, et al. Gender-specific outcomes after sirolimus-eluting stent implantation. J Am Coll Cardiol. 2007;50:2111–6.CrossRefPubMedCentralPubMedGoogle Scholar
  30. 30.
    Presbitero P, Belli G, Zavalloni D, et al. Gender paradox’ in outcome after percutaneous coronary intervention with paclitaxel eluting stents. EuroIntervention. 2008;4:345–50.CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Onuma Y, Kukreja N, Daemen J, et al. Impact of sex on 3-year outcome after percutaneous coronary intervention using bare-metal and drug-eluting stents in previously untreated coronary artery disease: insights from the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital). JACC Cardiovasc Interv. 2009;2:603–10.CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Seth A, Serruys PW, Lansky A, et al. A pooled gender based analysis comparing the XIENCE V(R) everolimus-eluting stent and the TAXUS paclitaxel-eluting stent in male and female patients with coronary artery disease, results of the SPIRIT II and SPIRIT III studies: two-year analysis. EuroIntervention. 2010;5:788–94.CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Stefanini GG, Baber U, Windecker S, et al. Safety and efficacy of drug-eluting stents in women: a patient-level pooled analysis of randomised trials. Lancet. 2013;382:1879–88.CrossRefPubMedCentralPubMedGoogle Scholar
  34. 34.
    Anderson ML, Peterson ED, Brennan JM, et al. Short- and long-term outcomes of coronary stenting in women versus men: results from the National Cardiovascular Data Registry Centers for Medicare & Medicaid services cohort. Circulation. 2012;126:2190–9.CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2016;134:e123–55.CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Montalescot G, Brieger D, Dalby AJ, Park S-J, Mehran R. Duration of dual antiplatelet therapy after coronary stenting: a review of the evidence. J Am Coll Cardiol. 2015;66:832–47.CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Gargiulo G, Ariotti S, Santucci A, et al. Impact of sex on 2-year clinical outcomes in patients treated with 6-month or 24-month dual-antiplatelet therapy duration: a pre-specified analysis from the PRODIGY trial. JACC Cardiovasc Interv. 2016;9:1780–9.CrossRefPubMedCentralPubMedGoogle Scholar
  38. 38.
    Yeh RW, Secemsky EA, Kereiakes DJ, et al. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA. 2016;315:1735–49.CrossRefPubMedCentralPubMedGoogle Scholar
  39. 39.
    Baber U, Mehran R, Giustino G, et al. Coronary thrombosis and major bleeding after PCI with drug-eluting stents: risk scores from PARIS. J Am Coll Cardiol. 2016;67:2224–34.CrossRefPubMedCentralPubMedGoogle Scholar
  40. 40.
    Costa F, van Klaveren D, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet. 2017;389:1025–34.CrossRefPubMedCentralPubMedGoogle Scholar
  41. 41.
    Sheiban I, La Spina C, Cavallero E, et al. Sex-related differences in patients undergoing percutaneous unprotected left main stenting. EuroIntervention. 2010;5:795–800.CrossRefPubMedCentralPubMedGoogle Scholar
  42. 42.
    Tamis-Holland JE, Lu J, Korytkowski M, et al. Sex differences in presentation and outcome among patients with type 2 diabetes and coronary artery disease treated with contemporary medical therapy with or without prompt revascularization: a report from the BARI 2D trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes). J Am Coll Cardiol. 2013;61:1767–76.CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Department of CardiologyKokura Memorial HospitalKitakyushuJapan
  2. 2.Department of Cardiovascular MedicineKyoto University Graduate School of MedicineKyotoJapan

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