Sex Differences in State-of-the-Art Management for Left Main Disease

Although higher mortality has been reported among women undergoing coronary revascularization for left main coronary artery disease (LMD), it remains unclear whether contemporary approaches can address these disparities. We investigated sex differences in outcomes using the DEFINE-LM (deferral of coronary revascularization based on instantaneous wave-free ratio evaluation for left main coronary artery disease) registry, in which state-of-the-art management was employed. We analyzed 314 patients from an international, multicenter registry, where all patients received state-of-the-art management, including physiology-guided revascularization decisions, intracoronary imaging-optimized drug-eluting stent deployment, or surgical procedures with internal thoracic artery grafts, alongside guideline-directed medical therapy. The cohort included 65 (20.7%) women and 249 (79.3%) men. The primary endpoint was a composite of death, nonfatal myocardial infarction (MI), and ischemia-driven target lesion revascularization of the left main stem (LM-TLR). Secondary endpoints were 1) cardiac death or spontaneous LMD-related MI and 2) LM-TLR. Patient and lesion characteristics were comparable, except for significantly higher age in women (70.1 ± 9.9 vs 67.6 ± 10.3, P = 0.02). At 30 months (Q1-Q3: 17-44), the primary endpoint occurred in 13.8% (9/65) of women and 11.2% (28/249) of men (HR: 1.15; 95% CI: 0.54-2.45; P = 0.71). Regarding secondary endpoints, no significant differences were observed in cardiac death or LMD-related MI (1.5% [1/65] vs 1.6% [4/249]; HR: 0.62; 95% CI: 0.07-5.34; P = 0.66) or LM-TLR (7.7% [5/65] vs 4.0% [10/249]; HR: 1.68; 95% CI: 0.57-4.94; P = 0.35). Cox regression analysis adjusting for age further demonstrated that patient sex was not a significant factor for the primary endpoint (P = 0.98). State-of-the-art LMD revascularization yielded comparable outcomes for women and men, despite women being significantly older.