Interventional Cardiology Unit Cardiovascular Institute, Hospital Universitario San Carlos, Plaza de Criso Rey, s/n, 28040 Madrid, Spain
* Correspondence to: Fernando Alfonso, Interventional Cardiology Unit, Cardiovascular Institute, Hospital Universitario San Carlo, Plaza de Criso Rey, s/n, 28040, Madrid, Spain. Tel: +34 91 549 4082; Fax: +34 91 330 3289
E-mail address: falf{at}hotmail.com
Received 1 September 2003; revised 23 September 2003; accepted 25 September 2003
We read with great interest the elegant study of Mehilli et al.1(August 16 Issue) suggesting that, as compared with men, women present a lower risk of restenosis after coronary stenting despite their adverse baseline characteristics. This large study, including 4374 patients treated with coronary stents (23% female) give us, for the first time, important insights which help to understand the favourable long-term outcome of women undergoing coronary stenting.
Many previous reports have demonstrated a higher number of acute procedural-related complications infemale patients. In addition, a worse cardiovascular risk profile has always been encountered among women.2,3However, paradoxically, the long-term prognosis of these patients has been consistently favourable.2,3In fact, as compared with their male counterparts women have a similar2or even better3long-term clinical outcome. A significant gender bias in the deliver of medical care, including lower number of adequate revascularization procedures at follow-up, has also been suggested.4
In a prior study2we demonstrated that in patients undergoing coronary stenting female gender had an independent influence on procedural-related complications (after adjusting for all potential confounders). However, the long-term clinical outcome of women was excellent and similar to that of men. Systematic late angiography, with quantitative coronary angiography, revealed a similar restenosis rate for women and men (30% vs 29%, respectively). As already pointed out,2this was a major surprise, since the baseline characteristics (age, prevalence of coronary risk factorsincluding diabetesand vessel size) of our female patients were significantly poorer that those found in man. Accordingly, women might be expected to have a higher risk for restenosis. The current study of Mehilli et al.,1including a larger number of patients, further expand this idea and emphasizes the relevance of a gender paradox by documenting a significantly lower restenosis rate in women that persisted after adjusting for confounding factors. In addition, they also demonstrated a major interactionbetween diabetes and gender suggesting that the influence of diabetes on restenosis was mostly confined to women. This is of great interest since the higher prevalence of diabetic women in our previous study (34% vs 28% in the current study) and the lower rate of diabetic men (16% vs 20% in the present study) could help to explain the lack of differences in the restenosis rate in our study.2Furthermore, the hypothesis provided by these investigators suggesting a potential protective role of estrogens is highly appealing, but should be considered on the light of the aged population of women included in most studies15and, therefore, should be further investigated.
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