Monday, September 3, 2007

ESC Congress - News - OASIS 5: Worse outcome with an invasive strategy among women with non ST-elevation acute coronary syndromes.

ESC Daily Congress News

OASIS 5: Worse outcome with an invasive strategy among women with non ST-elevation acute coronary syndromes.

Presenter report: Swahn, Eva (Sweden)

In patients with non ST-elevation acute coronary syndromes (NSTE ACS), subgroup analyses from several trials have shown a reduction in the composite of death and myocardial infarction with an early invasive strategy among men but a trend for harm amongst women. The aim of this study was to evaluate whether a routine early invasive strategy was superior to a selective invasive strategy in women.

The OASIS 5 Women sub-study randomized 184 women with NSTE ACS to either an early invasive strategy with routine coronary angiography (and, if appropriate, coronary revascularization within 7 days) or to a selective invasive strategy with ischemia guided coronary angiography. The outcomes death, myocardial infarction, refractory ischemia, major bleeding and stroke were evaluated after 2 years.

At one year follow-up 8 patients in the routine invasive group had died compared to 1 patient in the selective invasive group (8.8% vs 1.1%, p=0.013). There was no significant difference in either of the endpoints myocardial infarction (7.8% vs 9.9%, p= 0.634), refractory ischemia (4.4% vs 8.7%, p= 0.230) or stroke (2.3% vs 3.3%, p=0.872). Major bleedings were significantly more frequent in the routine invasive group (10.0% vs 1.1%, p= 0.002). The observed differences between the two groups, persisted at 2 years follow-up.

A routine invasive strategy was associated with an increased rate of major bleeding and mortality in women with NSTE ACS. As the majority of previous trials have predominantly enrolled men, a large randomized trial needs to be performed to determine the safety and efficacy of an early invasive approach in women.

Discussant : Rosengren, Annika (Sweden)

One of the most conspicuous differences in ACS between men and women is that women are older at the onset than men, probably owing to the protective effect of estrogen which seems to delay atherosclerosis in the coronary vessels. Coronary angiography usually shows less extensive atherosclerosis in women. The differences in clinical presentation between men and women are more marked in younger, compared to older, patients. Women have less ST-elevation ACS but instead more NSTE. However, it should be noted that young women with ACS are a minority, and that the great majority of women who present with ACS are elderly. As a result of their older age many women with ACS have other diseases. The issue whether women with ACS should be treated the same as men has been much debated. There is still little consensus whether modern treatment in ACS is a help in women to the same extent as in men.

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