**3.3 Ischemia-reperfusion time**

According to the statistics of the time from the onset of coronary artery disease to reperfusion ischemia time, the interval of female patients was longer than that of male patients, including the prehospital delay and the time from door to balloon [27–30]. A study by Lichtman et al. has revealed that the cardiovascular risk of female patients with coronary artery disease, especially young female patients with those, is not easy to be accurately assessed, which may lead to be delayed diagnosis of acute myocardial infarction, thereby affecting treatment and prognosis [31]. Another registration study from one of 11 centers in Switzerland providing primary PCI around the clock, which has demonstrated that female patients with acute myocardial infarction between 2005 and 2010 may be discriminated when they receive PCI [32]. It is speculated that this situation may also exist in other countries. The prognosis of female patients with coronary artery disease who are discriminated in clinic is partly poor. Moreover, a study from the United States has found that female patients with coronary artery disease were less likely to undergo PCI than male patients with those and more female patients with those had delayed time of ischemia-reperfusion [33]. These controllable factors can lead to the failure of female patients with coronary artery disease to improve myocardial ischemia effectively in a short period of time, which is one of the important factors of poor prognosis. The duration of ischemia-reperfusion may be longer in female patients with these atypical symptoms than in male patients, which is another factor of higher mortality and MACE in female patients with coronary artery disease after PCI.

**69**

*Gender Differences in Clinical Outcomes of Patients with Coronary Artery Disease…*

MACE is one of the factors that significantly affect the prognosis for patients with coronary artery disease after PCI. Previous study has indicated that the incidence of MACE is lower in male patients with coronary artery disease after PCI than that in female patients with those [9, 10, 23, 34]. A prospective, multicenter, cohort study by Glaser et al. has exhibited that female patients with non-ST-segment elevation acute coronary syndrome undergoing PCI at the age of 65 was more likely to have MACE than male patients with those at the same time [28]. Further analysis has shown that the incidence of congestive heart failure was higher in female patients with ST-segment elevation myocardial infarction than that in male patients with those, and the former was more likely to have cardiogenic shock when myocardial infarction occurred [5–7]. High incidence of ventricular septal rupture and severe mitral regurgitation during cardiogenic shock can be considered as important factors affecting the poor prognosis of female patients with myocardial infarction in the hospital. In a word, the above pathological factors can lead to the high incidence of MACE in female patients with coronary artery disease after PCI.

A study has demonstrated that the low incidence of revascularization in female patients with coronary artery disease may also be attributed to the lower follow-up rate, atypical symptoms, difficulty identifying myocardial ischemia, unwillingness to undergo invasive investigations, and prejudice against female patients [9]. In addition, the mortality of female patients with coronary artery disease was higher during the short- and long-term follow-up compared with male patients with those, which may also reduce the chance of revascularization [23, 34]. Furthermore, male patients with coronary artery disease who underwent PCI often have more complex lesions, which may be also an independent predictor of revascularization [23]. In terms of pathophysiology, the male subjects are more likely to have atherosclerotic plaque rupture, platelet-rich thrombus, and microembolism [35], while the platelets are more sensitive to aggregation stimulation in female patients, and this pathophysiological difference may also increase the risk of male patients with coronary artery disease who underwent PCI or CABG [36]. Moreover, some studies have shown that male patients with coronary artery disease have a higher PCI or CABG history than the female with those, which may be another reason for the higher incidence of overall revascularization in male

Earlier evidence has supported that the female individuals would experience depression after the initial diagnosis of coronary artery disease and acute cardiac events, leading to all-cause mortality and the risk of MACE in the following months [37, 38]. Breast cancer is one of the most important causes of female individual death worldwide. However, the administration of estrogen receptor modulators in anti-breast cancer treatments may increase the incidence of coronary artery disease [39]. The incidence of autoimmune diseases for female individuals is also high, especially systemic lupus erythematosus, which is more common in female individuals. The pathogenic antibodies of the disease can cause antiphospholipid antibody syndrome (thrombosis, thrombocytopenia), thereby involving coronary artery and even resulting in acute myocardial infarction [40]. Therefore, it is important

*DOI: http://dx.doi.org/10.5772/intechopen.91878*

**3.4 MACE**

**3.5 Revascularization**

patients with those [7, 8].

**3.6 Other risk factors**

*Gender Differences in Clinical Outcomes of Patients with Coronary Artery Disease… DOI: http://dx.doi.org/10.5772/intechopen.91878*

### **3.4 MACE**

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

Some studies have elucidated that gender differences in the prognosis of patients with coronary artery disease after PCI are due to the fundamental differences in physiology, pathophysiology, pathological anatomy, and other aspects between male and female. Anatomically, the coronary arteries of female patients with coronary artery disease are smaller than that of male patients with those, and the smaller blood vessels can cause higher risks of bleeding complications and vascular damage [22]. In general, male patients with coronary artery disease are prone to complex lesions, such as left main artery lesions, chronic total occlusion lesions, and long lesions, while female patients with coronary artery disease tend to have small vessel lesions, which are more likely to show no significant stenosis of the coronary artery during coronary angiography [23]. Meanwhile, coronary microvascular reactivity and myocardial response to ischemia are also different between male and female individuals. It is suggested that the hemodynamic state of female patients with coronary artery disease is worse than that of male patients with those, which leads to differences of cell cycle process and apoptosis-related protein levels of cardiac fibroblasts between different genders [24]. In addition, female patients with myocardial infarction often show atypical symptoms [25]. As a result, such patients will not be paid much attention to, and physicians may be misled or underestimate the possibility of acute coronary syndrome, thereby prolonging the time from myocardial infarction to revascularization [26]. These pathophysiology and anatomy differences are irreversible factors. If the physiological and pathological characteristics of female patients with coronary artery disease can be identified in time, appropriate coronary intervention strategies will be selected to reduce complications and improve their

According to the statistics of the time from the onset of coronary artery disease to reperfusion ischemia time, the interval of female patients was longer than that of male patients, including the prehospital delay and the time from door to balloon [27–30]. A study by Lichtman et al. has revealed that the cardiovascular risk of female patients with coronary artery disease, especially young female patients with those, is not easy to be accurately assessed, which may lead to be delayed diagnosis of acute myocardial infarction, thereby affecting treatment and prognosis [31]. Another registration study from one of 11 centers in Switzerland providing primary PCI around the clock, which has demonstrated that female patients with acute myocardial infarction between 2005 and 2010 may be discriminated when they receive PCI [32]. It is speculated that this situation may also exist in other countries. The prognosis of female patients with coronary artery disease who are discriminated in clinic is partly poor. Moreover, a study from the United States has found that female patients with coronary artery disease were less likely to undergo PCI than male patients with those and more female patients with those had delayed time of ischemia-reperfusion [33]. These controllable factors can lead to the failure of female patients with coronary artery disease to improve myocardial ischemia effectively in a short period of time, which is one of the important factors of poor prognosis. The duration of ischemia-reperfusion may be longer in female patients with these atypical symptoms than in male patients, which is another factor of higher mortality and MACE in female patients

**3.2 Anatomy and pathophysiology**

clinical prognosis.

**3.3 Ischemia-reperfusion time**

with coronary artery disease after PCI.

**68**

MACE is one of the factors that significantly affect the prognosis for patients with coronary artery disease after PCI. Previous study has indicated that the incidence of MACE is lower in male patients with coronary artery disease after PCI than that in female patients with those [9, 10, 23, 34]. A prospective, multicenter, cohort study by Glaser et al. has exhibited that female patients with non-ST-segment elevation acute coronary syndrome undergoing PCI at the age of 65 was more likely to have MACE than male patients with those at the same time [28]. Further analysis has shown that the incidence of congestive heart failure was higher in female patients with ST-segment elevation myocardial infarction than that in male patients with those, and the former was more likely to have cardiogenic shock when myocardial infarction occurred [5–7]. High incidence of ventricular septal rupture and severe mitral regurgitation during cardiogenic shock can be considered as important factors affecting the poor prognosis of female patients with myocardial infarction in the hospital. In a word, the above pathological factors can lead to the high incidence of MACE in female patients with coronary artery disease after PCI.

#### **3.5 Revascularization**

A study has demonstrated that the low incidence of revascularization in female patients with coronary artery disease may also be attributed to the lower follow-up rate, atypical symptoms, difficulty identifying myocardial ischemia, unwillingness to undergo invasive investigations, and prejudice against female patients [9]. In addition, the mortality of female patients with coronary artery disease was higher during the short- and long-term follow-up compared with male patients with those, which may also reduce the chance of revascularization [23, 34]. Furthermore, male patients with coronary artery disease who underwent PCI often have more complex lesions, which may be also an independent predictor of revascularization [23]. In terms of pathophysiology, the male subjects are more likely to have atherosclerotic plaque rupture, platelet-rich thrombus, and microembolism [35], while the platelets are more sensitive to aggregation stimulation in female patients, and this pathophysiological difference may also increase the risk of male patients with coronary artery disease who underwent PCI or CABG [36]. Moreover, some studies have shown that male patients with coronary artery disease have a higher PCI or CABG history than the female with those, which may be another reason for the higher incidence of overall revascularization in male patients with those [7, 8].

#### **3.6 Other risk factors**

Earlier evidence has supported that the female individuals would experience depression after the initial diagnosis of coronary artery disease and acute cardiac events, leading to all-cause mortality and the risk of MACE in the following months [37, 38]. Breast cancer is one of the most important causes of female individual death worldwide. However, the administration of estrogen receptor modulators in anti-breast cancer treatments may increase the incidence of coronary artery disease [39]. The incidence of autoimmune diseases for female individuals is also high, especially systemic lupus erythematosus, which is more common in female individuals. The pathogenic antibodies of the disease can cause antiphospholipid antibody syndrome (thrombosis, thrombocytopenia), thereby involving coronary artery and even resulting in acute myocardial infarction [40]. Therefore, it is important

to prevent and reduce the incidence of female high-risk diseases and to reduce the mortality and MACE of female patients with coronary artery disease after PCI.
