Gender-based disparities in outcomes of coronary bifurcation stenting in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis.

Am J Cardiovasc Dis 2024;14(3):136-143 www.AJCD.us /ISSN:2160-200X/AJCD0156039 Review Article Gender-based disparities in outcomes of coronary bifurcation stenting in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis Resha Khanal1, Mohammad Hamza2, Maria Najam3, Salman Abdul Basit4, Zarghoona Wajid5, Amna Rashdi6, Neel Patel7, Saman Razzaq8, Rajendra Shah9, Khaled M Harmouch8, Bandar Alyami10, Yasemin Bahar11, Muhammad Aamir12, Mohammed Abu-Mahfouz13, Yasar Sattar10, M Chadi Alraies13 Department of Internal Medicine, Wayne Health University/Detroit Medical Center, Detroit, MI, USA; 2Guthrie Medical Group, Cortland, NY, USA; 3Department of Internal Medicine, University of Texas Rio Grande Valley, Weslaco, TX, USA; 4The Wright Center for GME, Scranton, PA, USA; 5Wayne State University School of Medicine, Detroit, MI, USA; 6Windsor Heart Institute, Windsor, ON, Canada; 7New York Medical College/Landmark Medical Center, Woonsocket, RI, USA; 8Detroit Medical Center/Wayne State University, Detroit, MI, USA; 9University of Florida/ Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, USA; 10Department of Cardiology, West Virginia University, Morgantown, WV, USA; 11Wayne State University, Detroit, MI, USA; 12Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA; 13Cardiovascular Institute, Detroit Medical Center, Detroit, MI, USA 1 Received February 21, 2024; Accepted May 16, 2024; Epub June 15, 2024; Published June 30, 2024 Abstract: Introduction: Around 15-20% of lesions necessitating percutaneous coronary interventions (PCI) are attributed to coronary bifurcation lesions. We aim to study gender-based differences in PCI outcomes among bifurcation stents. Methods: 3 studies were included after thorough systematic search using MEDLINE (EMBASE and PubMed). CRAN-R software using the Metabin module was used for statistical analysis. Pooled odds ratios (OR) were calculated using the random effect model and the Mantel-Haenszel method, with a 95% confidence interval (CI) used to determine statistical significance. Heterogeneity was assessed using Higgins I2. Result: Women exhibited a higher risk of in-hospital mortality (OR 0.67, 95% CI 0.58-0.76, I2 = 0%, P < 0.0001), post-procedural bleeding (OR 0.53, 95% CI 0.47-0.6, I2 = 0%, P < 0.0001) and post-procedure stroke (OR 0.72, 95% CI 0.52-1.0, I2 = 0%, P < 0.06) as compared to men. However, there were no significant differences in terms of myocardial infarction (OR 0.84, 95% CI 0.22-3.27, I2 = 49.4%, P < 0.80) and cardiac tamponade (OR 0.63, 95% CI 0.06; 5.72, I2 = 0%, P < 0.6821) in both groups. Conclusion: Our study reveals a noteworthy increase in in-hospital mortality in women, which could be attributed to a higher rate of major bleeding, advanced age, increased co-morbidities, and complex pathophysiology of the lesion in comparison to men. Further studies are required to gain a better understanding of the precise mechanisms thus enhancing procedural outcomes. Keywords: Female, male, bifurcation stenting, PCI Introduction Cardiovascular disease remains a leading cause of mortality in the United States. Among various treatment modalities for coronary artery disease (CAD), percutaneous coronary intervention (PCI) has evolved as a major therapeutic intervention for obstructive coronary pathologies. PCI was introduced in 1977 and has played a vital role in reducing mortality and overall survival outcomes in patients with CAD [1]. Over time, with an increasing prevalence of CAD, it is imperative to understand the effectiveness of PCI for intricate lesions and advanced CAD such as coronary bifurcation lesions to improve patients’ quality of life. Advanced coronary lesions with complex anatomy are a unique challenge for adverse outcomes during stent placement [2]. The growth of interventional cardiology has led to better success rates and decreased incidence of in- https://doi.org/10.62347/YBJN2231 Gender-based disparities and bifurcation stenting Table 1. Characteristics of included studies Author Pravda et al. Osman et al. Nicolas et al. Year 2021 2021 2020 Country Israel United States United States Duration of study 3 years 30 days 3 years Type of the study Observational National Inpatient Data Observational Primary outcomes In-hospital mortality. MACE In-hospital mortality. Major bleeding, 30-day readmission Secondary outcomes Stent thrombosis, in-stent restenosis, CABG, target lesions revascularization stent restenosis particularly in the subset of bifurcating coronary stents which approximately accounts for 15-20% of all coronary lesions requiring PCI [3]. There are notable studies that focus on outcomes of PCI in bifurcating lesions focusing on major adverse cardiac events (MACE) eg: bleeding, stent thrombosis, target lesion revascularization (TLR), and mortality, but the impact of patient factors, especially the effect of gender, is currently limited and still an area of ongoing research and a subject of interest in recent medical research [4]. Recent studies exploring gender disparities indicate that women experience far much worse outcomes compared to men undergoing PCI for coronary bifurcation lesions [5]. Recognizing the knowledge gap, this meta-analysis aims to review the currently existing literature in detail and to summarize and give valuable insight on gender-specific influences, thereby contributing towards further understanding and refinement of management strategies in men and women, leading to the ultimate goal of better patient care, clinical decision making while managing coronary artery disease, future research, and optimization of resources in health. Methods Study design Our approach to searching and conducting the meta-analysis aligns with the recommendations outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews-2) guidelines [6, 7]. The checklists of these guidelines are presented in Supplementary Files 1 and 2 respectively. 137 MACE In-hospital mortality, vascular complications, major bleeding, Stent thrombosis, major post-procedural bleeding, need for blood transfusion, AKI, AKI bleeding, minor bleeding requiring dialysis, stroke, severe disability, length of stay and cost of hospitalization, 30-day readmission Inclusion and exclusion criteria We conducted a literature search on MEDLINE (Pubmed and Scopus) for trials or observational studies using a systematic search strategy as per PRISMA guidelines. We included studies that investigated disparities related to gender in patients aged 18 or older with stable coronary artery disease or acute coronary syndrome and underwent any form of percutaneous coronary intervention (PCI) involving stent placement at the bifurcation of coronary arteries (Table 1). Case reports, clinical spotlights, and review articles were excluded. Screening We utiliz (...truncated)