Sex-specific outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in women with coronary artery disease: a systematic review and meta-analysis
P G Batista, G C Gaelzer, R R A Santos Silva, M V Montenegro, M Malik, M Dandamudi, J Peres de Oliveira, M E Molinari, L A Lucena, R Huntermann, C Fischer Bacca, J GiorgiAbstract
Introduction
Coronary artery disease (CAD) remains the leading cause of morbidity and mortality in women, yet women are underrepresented in revascularization trials, and treatment decisions are often extrapolated from predominantly male populations. Given established sex-related differences in coronary anatomy, comorbidity burden, and procedural risk, uncertainty persists regarding the comparative effectiveness of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in women.
Purpose
To perform a comprehensive time-to-event meta-analysis comparing PCI and CABG in women with CAD.
Methods
We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for eligible studies. Outcomes included all-cause mortality, repeat revascularization, major adverse cardiovascular events (MACE), myocardial infarction, and stroke. Hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were pooled using random-effects models to account for between-study variability. Statistical heterogeneity was quantified using the I² statistic. A two-sided P-value of < 0.05 was considered statistically significant.
Results
We included women from 42 studies. The follow-up ranged from 1 to 10 years. Compared with CABG, PCI was associated with a statistically significant higher risk of all-cause mortality (25 studies, 74,292 women; HR, 1.26; 95% CI, 1.15-1.38; I² = 56.7%; P < 0.0001), repeat revascularization (12 studies, 22,884 women; HR, 3.13; 95% CI, 2.22-4.41; I² = 87.3%; P < 0.0001), MACE (17 studies, 22,816 women; HR, 1.15; 95% CI, 1.00-1.32; I² = 49.7%; P = 0.0483), myocardial infarction (6 studies, 15,140 women; HR, 2.03; 95% CI, 1.52-2.70; I² = 54.5%; P = 0.0015). In contrast, PCI was associated with lower rates of stroke (5 studies, 16,660 women; HR, 0.69; 95% CI, 0.48-0.97; I² = 47.9%; P = 0.0402).
Conclusions
In women with CAD, CABG was associated with lower risks of mortality, repeat revascularization, MACE, and myocardial infarction compared with PCI, albeit at the expense of a higher risk of stroke. Overall, these findings indicate a prognostic advantage of surgical revascularization in women and underscore the urgent need for dedicated sex-specific randomized trials to better inform treatment selection.