Percutaneous Coronary Intervention: Special Considerations in Women

  • Lucy BlowsEmail author
  • Timothy Williams


Coronary artery disease (CAD) is a leading cause of death in men and women, although historically there has been more of a focus on its importance in men. Biological differences between the sexes impact on the nature of the disease in men and women, with implications for diagnosis and management. Furthermore, the unique hormonal changes resulting from pregnancy and the menopause require special consideration when managing CAD in women. While CAD is a killer of both sexes, women are proportionally more affected, with it accounting for more deaths than from cancer, chronic respiratory disease, Alzheimer’s disease and accidents combined. Although overall mortality had been in decline, the rate of CAD in young women has been increasing since 1980. In this chapter we explore the special considerations that need to be taken into account when managing CAD in women who go on to require percutaneous coronary intervention.


Coronary artery disease Acute coronary syndrome Coronary artery disease in women Coronary intervention Coronary artery disease in pregnancy Spontaneous coronary artery dissection Cardiovascular disease STEMI NSTEMI 


  1. 1.
    Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American heart association. Circulation. 2012;125(1):e2–e220. Scholar
  2. 2.
    Ford ES, Capewell S. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002. J Am Coll Cardiol. 2007;50(22):2128–32. Scholar
  3. 3.
    Wilson PWF, D’Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Arch Intern Med. 2002;162(16):1867–72. Accessed May 20, 2017.CrossRefPubMedGoogle Scholar
  4. 4.
    Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332(7533):73–8. Accessed May 20, 2017.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Willett WC, Green A, Stampfer MJ, et al. Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. N Engl J Med. 1987;317(21):1303–9. Scholar
  6. 6.
    Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ. 1998;316(7137):1043–7. Accessed May 20, 2017CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Orth-Gomér K, Wamala SP, Horsten M, Schenck-Gustafsson K, Schneiderman N, Mittleman MA. Marital stress worsens prognosis in women with coronary heart disease: the Stockholm Female Coronary Risk Study. JAMA. 2000;284(23):3008–14. Accessed May 20, 2017.CrossRefPubMedGoogle Scholar
  8. 8.
    Wassertheil-Smoller S, Shumaker S, Ockene J, et al. Depression and cardiovascular sequelae in postmenopausal women. The Women’s Health Initiative (WHI). Arch Intern Med. 2004;164(3):289–98. Scholar
  9. 9.
    Dickerson JA, Nagaraja HN, Raman SV. Gender-related differences in coronary artery dimensions: a volumetric analysis. Clin Cardiol. 2010;33(2):E44–9. Scholar
  10. 10.
    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(11):1359–69. Scholar
  11. 11.
    Sullivan AK, Holdright DR, Wright CA, Sparrow JL, Cunningham D, Fox KM. Chest pain in women: clinical, investigative, and prognostic features. BMJ. 1994;308(6933):883–6. Scholar
  12. 12.
    Glaser R, Herrmann HC, Murphy SA, et al. Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA. 2002;288(24):3124–9. Accessed May 20, 2017.CrossRefPubMedGoogle Scholar
  13. 13.
    Reis SE, Holubkov R, Conrad Smith AJ, et al. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J. 2001;141(5):735–41. Accessed May 20, 2017.CrossRefPubMedGoogle Scholar
  14. 14.
    Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 2015;373(10):929–38. Scholar
  15. 15.
    Graham G. Acute coronary syndromes in women: recent treatment trends and outcomes. Clin Med Insights Cardiol. 2016;10:1–10. Scholar
  16. 16.
    Mehta LS, Beckie TM, DeVon HA, et al. Acute myocardial infarction in women. Circulation. 2016;133(9):916–47.CrossRefPubMedGoogle Scholar
  17. 17.
    Bucholz EM, Butala NM, Rathore SS, Dreyer RP, Lansky AJ, Krumholz HM. Sex differences in long-term mortality after myocardial infarction: a systematic review. Circulation. 2014;30(9):757–67.CrossRefGoogle Scholar
  18. 18.
    Hochman JS, Tamis JE, Thompson TD, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. N Engl J Med. 1999;341(4):226–32. Scholar
  19. 19.
    van der Meer MG, Nathoe HM, van der Graaf Y, Doevendans PA, Appelman Y. Worse outcome in women with STEMI: a systematic review of prognostic studies. Eur J Clin Invest. 2015;45(2):226–35. Scholar
  20. 20.
    Kunadian V, Qiu W, Lagerqvist B, et al. Gender differences in outcomes and predictors of all-cause mortality after percutaneous coronary intervention (Data from United Kingdom and Sweden). Am J Cardiol. 2017;119(2):210–6. Scholar
  21. 21.
    Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010;121(7):948–54. Scholar
  22. 22.
    Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J. 1986;111(2):383–90. Accessed February 22, 2017.CrossRefPubMedGoogle Scholar
  23. 23.
    Gordon T, Kannel WB, Hjortland MC, McNamara PM. Menopause and coronary heart disease. The Framingham Study. Ann Intern Med. 1978;89(2):157–61. Accessed February 22, 2017.CrossRefPubMedGoogle Scholar
  24. 24.
    Muka T, Oliver-Williams C, Kunutsor S, et al. Association of age at onset of menopause and time since onset of menopause with cardiovascular outcomes, intermediate vascular traits, and all-cause mortality. JAMA Cardiol. 2016;1(7):767. Scholar
  25. 25.
    Mazza A, Tikhonoff V, Schiavon L, Casiglia E. Triglycerides + high-density-lipoprotein-cholesterol dyslipidaemia, a coronary risk factor in elderly women: the CArdiovascular STudy in the ELderly. Intern Med J. 2005;35(10):604–10. Scholar
  26. 26.
    Milner KA, Vaccarino V, Arnold AL, Funk M, Goldberg RJ. Gender and age differences in chief complaints of acute myocardial infarction (Worcester heart attack study). Am J Cardiol. 2004;93(5):606–8. Scholar
  27. 27.
    Philpott S, Boynton PM, Feder G, Hemingway H. Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation study. Soc Sci Med. 2001;52(10):1565–75. Accessed May 20, 2017.CrossRefPubMedGoogle Scholar
  28. 28.
    Goldberg RJ, O’Donnell C, Yarzebski J, Bigelow C, Savageau J, Gore JM. Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J. 1998;136(2):189–95. Scholar
  29. 29.
    Kreatsoulas C, Shannon HS, Giacomini M, Velianou JL, Anand SS. Reconstructing angina: cardiac symptoms are the same in women and men. JAMA Intern Med. 2013;173(9):829. Scholar
  30. 30.
    Pepine CJ, Abrams J, Marks RG, Morris JJ, Scheidt SS, Handberg E. Characteristics of a contemporary population with angina pectoris. TIDES investigators. Am J Cardiol. 1994;74(3):226–31. Accessed February 26, 2017.CrossRefPubMedGoogle Scholar
  31. 31.
    Jónsdóttir LS, Sigfusson N, Sigvaldason H, Thorgeirsson G. Incidence and prevalence of recognised and unrecognised myocardial infarction in women. The Reykjavik Study. Eur Heart J. 1998;19(7):1011–8. Accessed February 26, 2017.CrossRefPubMedGoogle Scholar
  32. 32.
    Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813–22. Scholar
  33. 33.
    Stangl V, Witzel V, Baumann G, Stangl K. Current diagnostic concepts to detect coronary artery disease in women. Eur Heart J. 2008;29(6):707–17. Scholar
  34. 34.
    Gerber TC, Carr JJ, Arai AE, et al. Ionizing radiation in cardiac imaging. Circulation. 2009;119(7):1056–65.CrossRefPubMedGoogle Scholar
  35. 35.
    Vrints CJM. Spontaneous coronary artery dissection. Heart. 2010;96(10):801–8. Scholar
  36. 36.
    Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry Study. Catheter Cardiovasc Interv. 2009;74(5):710–7. Scholar
  37. 37.
    Nishiguchi T, Tanaka A, Ozaki Y, et al. Prevalence of spontaneous coronary artery dissection in patients with acute coronary syndrome. Eur Heart J Acute Cardiovasc Care. 2016;5(3):263–70. Scholar
  38. 38.
    Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation. 2012;126(5):579–88. Scholar
  39. 39.
    Thompson EA, Ferraris S, Gress T, Ferraris V. Gender differences and predictors of mortality in spontaneous coronary artery dissection: a review of reported cases. J Invasive Cardiol. 2005;17(1):59–61. Accessed February 22, 2017.PubMedGoogle Scholar
  40. 40.
    Saw J, Aymong E, Mancini GBJ, Sedlak T, Starovoytov A, Ricci D. Nonatherosclerotic coronary artery disease in young women. Can J Cardiol. 2014;30(7):814–9. Scholar
  41. 41.
    Motreff P, Malcles G, Combaret N, et al. How and when to suspect spontaneous coronary artery dissection? Novel insights from a single-center series on prevalence and angiographic appearance. EuroIntervention. 2017;12(18):e2236–43. Scholar
  42. 42.
    Alfonso F. Spontaneous coronary artery dissection. Circulation. 2012;126(6):667–70.CrossRefPubMedGoogle Scholar
  43. 43.
    Saw J, Aymong E, Sedlak T, et al. Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes. Circ Cardiovasc Interv. 2014;7(5):645–55. Scholar
  44. 44.
    Alfonso F, Bastante T, Cuesta J, Rodríguez D, Benedicto A, Rivero F. Spontaneous coronary artery dissection: novel insights on diagnosis and management. Cardiovasc Diagn Ther. 2015;5(2):133–40. Scholar
  45. 45.
    Saw J. Coronary angiogram classification of spontaneous coronary artery dissection. Catheter Cardiovasc Interv. 2014;84(7):1115–22. Scholar
  46. 46.
    Vanzetto G, Berger-Coz E, Barone-Rochette G, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. Eur J Cardiothoracic Surg. 2009;35(2):250–4. Scholar
  47. 47.
    Blomkalns AL, Chen AY, Hochman JS, et al. Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementatio). J Am Coll Cardiol. 2005;45(6):832–7. Scholar
  48. 48.
    Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):2354–94. Scholar
  49. 49.
    O’Donoghue M, Boden WE, Braunwald E, et al. Early invasive vs conservative treatment strategies in women and men with unstable angina and non–ST-segment elevation myocardial infarction. JAMA. 2008;300(1):71. Scholar
  50. 50.
    D’Onofrio G, Safdar B, Lichtman JH, et al. Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation. 2015;131(15):1324–32. Scholar
  51. 51.
    Reynolds HR, Srichai MB, Iqbal SN, et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation. 2011;124(13):1414–25. Scholar
  52. 52.
    Cenko E, Bugiardini R. Vasotonic angina as a cause of myocardial ischemia in women. Cardiovasc Drugs Ther. 2015;29(4):339–45. Scholar
  53. 53.
    Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(24):3147–97. Scholar
  54. 54.
    Bush N, Nelson-Piercy C, Spark P, et al. Myocardial infarction in pregnancy and postpartum in the UK. Eur J Prev Cardiol. 2013;20(1):12–20. Scholar
  55. 55.
    Ladner HE, Danielsen B, Gilbert WM. Acute myocardial infarction in pregnancy and the puerperium: a population-based study. Obstet Gynecol. 2005;105(3):480–4. Scholar
  56. 56.
    James AH, Jamison MG, Biswas MS, Brancazio LR, Swamy GK, Myers ER. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation. 2006;113(12):1564–71. Scholar
  57. 57.
    Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. J Am Coll Cardiol. 2008;52(3):171–80. Scholar
  58. 58.
    Pieper PG, Hoendermis ES, Drijver YN. Cardiac surgery and percutaneous intervention in pregnant women with heart disease. Neth Heart J. 2012;20(3):125–8. Scholar
  59. 59.
    Yarrington CD, Valente AM, Economy KE. Cardiovascular management in pregnancy: antithrombotic agents and antiplatelet agents. Circulation. 2015;132(14):1354–64. Scholar
  60. 60.
    Pandie S, Mehta SR, Cantor WJ, et al. Radial versus femoral access for coronary angiography/intervention in women with acute coronary syndromes. JACC Cardiovasc Interv. 2015;8(4):505–12. Scholar
  61. 61.
    Pristipino C, Pelliccia F, Granatelli A, et al. Comparison of access-related bleeding complications in women versus men undergoing percutaneous coronary catheterization using the radial versus femoral artery. Am J Cardiol. 2007;99(9):1216–21. Scholar
  62. 62.
    Wang TY, Angiolillo DJ, Cushman M, et al. Platelet biology and response to antiplatelet therapy in women: implications for the development and use of antiplatelet pharmacotherapies for cardiovascular disease. J Am Coll Cardiol. 2012;59(10):891–900. Scholar
  63. 63.
    Alexander KP, Chen AY, Newby LK, et al. Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) initiative. Circulation. 2006;114(13):1380–7. Scholar
  64. 64.
    Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115(11):1481–501. Scholar
  65. 65.
    Daly C. Gender differences in the management and clinical outcome of stable angina. Circulation. 2006;113(4):490–8. Scholar
  66. 66.
    Collaborative overview of randomised trials of antiplatelet therapy Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ. 1994;308(6921):81–106.
  67. 67.
    Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324(7329):71–86. Accessed March 7, 2017.CrossRefGoogle Scholar
  68. 68.
    de Gaetano G, Collaborative Group of the Primary Prevention Project. Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general practice. Collaborative Group of the Primary Prevention Project. Lancet (London, England). 2001;357(9250):89–95. Accessed March 7, 2017.CrossRefGoogle Scholar
  69. 69.
    Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet (London, England). 1986;2(8498):57–66. Accessed March 7, 2017.
  70. 70.
    Pfeffer MA, Braunwald E, Moyé LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 1992;327(10):669–77. Scholar
  71. 71.
    Lewis SJ, Sacks FM, Mitchell JS, et al. Effect of pravastatin on cardiovascular events in women after myocardial infarction: the cholesterol and recurrent events (CARE) trial. J Am Coll Cardiol. 1998;32(1):140–6. Accessed March 7, 2017.CrossRefPubMedGoogle Scholar
  72. 72.
    Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med. 1996;335(14):1001–9. Scholar
  73. 73.
    Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350(15):1495–504. Scholar
  74. 74.
    Berger JS, Bhatt DL, Cannon CP, et al. The relative efficacy and safety of clopidogrel in women and men. J Am Coll Cardiol. 2009;54(21):1935–45. Scholar
  75. 75.
    Husted S, James SK, Bach RG, et al. The efficacy of ticagrelor is maintained in women with acute coronary syndromes participating in the prospective, randomized, PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J. 2014;35(23):1541–50. Scholar
  76. 76.
    Taddei S, Virdis A, Ghiadoni L, et al. Menopause is associated with endothelial dysfunction in women. Hypertens (Dallas, Tex 1979). 1996;28(4):576–82. Accessed March 7, 2017.CrossRefGoogle Scholar
  77. 77.
    Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA. 1998;280(7):605–13. Accessed March 7, 2017.CrossRefPubMedGoogle Scholar
  78. 78.
    Grady D, Herrington D, Bittner V, et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: heart and estrogen/progestin replacement study follow-up (HERS II). JAMA. 2002;288(1):49–57. Accessed March 7, 2017.CrossRefPubMedGoogle Scholar
  79. 79.
    Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321–33. Accessed March 7, 2017.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS TrustBrightonUK

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