Patient population

All patients who receive PCI in both private and public hospitals are registered prospectively and consecutively into a database at the Regional Hospitalization Agency (Midi-Pyrenées, France), which evaluates the quality of care provided to patients treated with angioplasty. The data used in this investigation was extracted from the database and related to 9089 patients treated by PCI in our hospital (Rangueil University Hospital, Toulouse, France) during a 3.5-year period (January 2005 to June 2008). Data from all patients who received PCI were included in our analyses; there were no exclusion criteria. Patients who were in the hospital for less than 48 h were contacted by phone. Demographic information, diagnoses and 48-hour outcomes were entered in a uniform registry format and then sent mandatorily to the Regional Hospitalization Agency for all patients.

Data were analysed for two patient categories: emergency PCI-STEMI (i.e., patients admitted with STEMI who received primary emergency PCI or rescue emergency PCI after thrombolysis failed) and non-emergency PCI (i.e., patients who received non-emergency PCI for acute coronary syndromes or stable angina). The decision to perform emergency PCI was based on guidelines established by the American Heart Association . Primary emergency PCI was performed in patients presenting less than 12 h after the onset of chest pain or other symptoms, who were not administered thrombolysis therapy; rescue PCI was performed when thrombolysis was unsuccessful for 90 min after initiating bolus administration of the thrombolytic agent. STEMI was defined as typical acute chest pain with persistent (> 20 min) ST-elevation. Non-emergency procedures were performed in patients with non-ST-elevation acute coronary syndromes or as elective intervention in patients with stable coronary artery disease and proof of ischaemia. All PCI procedures were performed by senior interventional cardiologists via standard techniques, including balloon angioplasty, stent implantation, and (when debulking was necessary) mechanical rotational atherectomy. Adjunctive medications for PCI were administered in agreement with the European Society of Cardiology guidelines .

Study variables and endpoints

The primary endpoint of this study was the frequency of cardiac or non-cardiac death within 48 h after completion of the PCI procedure; information on outcomes after discharge was not available. Secondary endpoints included the frequency of recurrent myocardial infarction, new PCI or coronary artery bypass graft (CABG), stroke, and major vascular or renal complications; the occurrence of any secondary endpoint was also calculated. A diagnosis of recurrent myocardial infarction was based on recurrent chest pain (> 20 min) accompanied by re-elevation of cardiac enzyme levels and/or new ST-segment elevation determined via electrocardiography. Major vascular events were defined as any vascular access site complication that required surgical vascular repair or blood transfusion. Stroke was defined as the occurrence of persistent specific neurological deficits. Major renal events were defined as acute renal failure that required renal haemodialysis.

Statistical methods

Data for the emergency PCI-STEMI and non-emergency PCI groups were analysed separately. Statistical analyses were performed with SAS statistical software, version 9.2 (SAS Institute Inc., Cary, NC, USA). A p value less than 0.05 was considered statistically significant. Mean values for age were compared with the Student’s t -test after verification of the distribution of residuals and the homogeneity of variances. For bivariate analyses, the distribution of qualitative variables was assessed with the χ ² test. The Fisher’s exact test was computed as needed. Analyses stratified for age (< or ≥ 75 years) and history of renal failure were performed with the Cochran-Mantel-Haenszel (CMH) test. Independent associations between gender and in-hospital outcome were assessed via multivariate logistic regression. Systematic adjustments were performed for age, history of coronary artery disease, renal failure, year of procedure, number of vessels affected and number of vessels treated.

To mitigate differences in baseline characteristics, pair analyses were performed via a propensity-score weighting method , which can reduce bias in measured characteristics. A single propensity score was calculated to represent the relationship between an outcome and several characteristics, then a sequential matching pair analysis, from five to three digits of the predicted probability, was performed with patients of each gender who had equivalent propensity scores. The probability (i.e., the odds ratio [OR]) that the event occurred in women rather than in men was calculated via logistic regression.

Patient population and basic characteristics

More than 9000 patients were included: 1753 patients in the emergency PCI-STEMI group and 7336 patients in the non-emergency PCI group ( Fig. 1 ); less than 10% of patients in the emergency PCI-STEMI group were referred for emergency PCI after thrombolysis failure. All PCI procedures were performed between January 2005 and June 2008 in a single centre by six experienced senior operators. Patients’ baseline characteristics are summarized by gender in Table 1 . The proportions of women in the emergency PCI-STEMI group (23.4%) and the non-emergency PCI group (22.7%) were similar. In both groups, women were older than men ( p < 0.0001) and more frequently had a history of renal failure ( p < 0.0001), but men were more likely to have a history of coronary artery disease and previous PCI; in the non-emergency PCI group, men were more likely than women to have a history of myocardial infarction or CABG. All other baseline characteristics were similar between genders, and there were no significant differences in the proportions of men and women with multi-vessel disease, in the number of vessels treated or in the use of thrombolytic therapy. After propensity-score matching, baseline characteristics of men and women were similar in both PCI groups (data not shown).

Patient flow diagram. PCI: Percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction.

Table 1

Baseline characteristics.

	Emergency PCI-STEMI ( n = 1753)			Non-emergency PCI ( n = 7336)
	Men ( n = 1343)	Women ( n = 410)	p	Men ( n = 5668)	Women ( n = 1668)	p
Age (years)	62.3 (13.5)	71.1 (13.5)	0.0001	65.6 (12.2)	71.7 (11.5)	0.0001
Age ≥ 75 years	22.7	48.1	0.0001	27.5	49.3	0.0001
Year of procedure			0.32			0.16
2005	28.7	25.1		24.8	24.9
2006	28.2	31.5		28.4	30.5
2007	28.7	27.3		29.4	29.3
2008	14.4	16.1		17.4	15.3
History
Myocardial infarction	5.1	3.7	0.25	10.7	7.2	0.0001
PCI	13.9	10.0	0.04	32.2	24.4	0.0001
CABG	3.7	1.7	0.05	8.1	5.4	0.0003
Coronary artery disease	17.7	13.2	0.04	39.5	29.4	0.0001
Other vascular disease	2.7	2.9	0.79	3.4	4.1	0.17
Renal failure	9.5	19.3	0.0001	14.7	21.1	0.0001
Number of diseased vessels a			0.71			0.04
One	37.1	39.0		26.3	28.7
Two	21.7	21.7		20.2	21.1
Three	35.3	31.7		45.5	41.4
Unknown	5.9	7.6		8.0	8.8
Number of treated vessels			0.60			0.56
One	80.6	80.5		63.1	64.4
Right coronary	28.6	29.8		19.6	20.4
Left circumflex	15.3	11.2		16.9	13.8
Left anterior descending	36.7	39.5		26.6	30.2
Two	12.2	12.4		20.7	19.0
Three	3.9	4.9		11.3	11.6
Unknown	3.3	2.2		4.9	5.0
Stent	87.8	91.0	0.08	91.6	91.6	0.66
Thrombolytic therapy	9.7	8.1	0.31

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