Gender Differences in Clinical Outcomes After

Percutaneous Coronary Intervention—Analysis of

15,106 Patients from the Cardiac Registry of Pakistan
Database
Ghazal Peerwani, MSca, Saud Munib Khan, MBBSb, Mustafa Dilawar Khan, MBBSb,
Faiza Bashir, MBBSb, Sana Sheikh, MSca, David J. Ramsey, PhDc,d, Saba Aijaz, MBBS, FCPSa,e,
Zainab Samad, MD, MSf, Rehan Malik, MBAa, Bashir Hanif, MDe, and Salim S. Virani, MD, PhDc,d,*

There is a scarcity of data on gender differences in outcomes during and after percutane-
ous coronary intervention (PCI) in the South Asian population. We assessed the gender
differences in in-hospital mortality and complications in patients who underwent PCI. We
conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of
Pakistan) CathPCI database. Logistic regression was used to determine factors associated
with in-hospital mortality (primary outcome), access site hematoma, and bleeding compli-
cations. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4
years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs
56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs
0.8%) than men (p <0.05).Unadjusted in-hospital mortality was higher in women than in
men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjust-
ing for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation
myocardial infarction at presentation in the multiple logistic regression model, in-hospital
mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8
to 1.7). The results remained consistent after propensity score matching of 5,904 patients
(2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding compli-
cations (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs
0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the
incidence of in-hospital mortality was higher for women versus men, but adjusted risks
were similar, likely driven by a greater co-morbidity burden among women. Published
by Elsevier Inc. (Am J Cardiol 2023;188:61−67)

Worldwide, 1/3 of all deaths in women are attributed
to cardiovascular diseases.1 Women with cardiovascular
disease have a worse prognosis and higher mortality
than men.2,3 This gender disparity also extends to
patients with acute coronary syndrome who have under-
gone percutaneous coronary intervention (PCI). Findings
from US National CathPCI registry suggest higher unad-
justed in-hospital mortality (1.7% vs 1.1%) and post-
PCI complications (8.3% vs 5.4%) in women than in
men.4 Factors explaining this disparity in post-PCI out-
comes between men and women include older age and
higher baseline risk in women.4−6 In addition, the
inherent biologic differences, including differences in
gene expressions that affect cardiovascular functions or
a
Departments of Clinical Research Cardiology; bMedical College,
Ziauddin University, Karachi, Pakistan; cMichael E. DeBakey Veterans
Affairs Medical Center, Houston, Texas; dDepartment of Medicine, Baylor
College of Medicine, Houston, Texas; eClinical Cardiology, Tabba Heart
Institute, Karachi, Pakistan; and fDepartment of Medicine, Aga Khan Uni-
versity, Karachi, Pakistan. Manuscript received July 8, 2022; revised manu-
script received and accepted November 10, 2022.
Funding: none.
See page 66 for disclosure information.
*Corresponding author: Tel: 713-440-4410; fax: 713-748-7359.
E-mail address: virani@bcm.edu (S.S. Virani).
differences in hormones might also play a role in this
disparity.7 Finally, barriers in healthcare access because of
social or cultural norms, out-of-pocket health expenditures,
and delayed treatment in women because of more atypical
presentation can also attribute to worse post-PCI outcomes
in women, especially in low- and middle-income coun-
tries.7 There is a scarcity of large-scale studies highlight-
ing the gender differences in presentation and post-PCI
outcomes in the South Asian (SA) population. Delayed
presentation and limited healthcare access in this region of
the world can be exaggerated in women compared with
men because of sociocultural barriers. To study this possi-
ble gender disparity, we aimed to determine the gender
differences in in-hospital mortality and complications in
patients who underwent PCI and captured in the CROP
(Cardiac Registry of Pakistan). We also explored factors
associated with in-hospital mortality and other post-PCI
complications.
Methods
The data on 15,106 patients were extracted from the
CROP CathPCI database, which includes 25 facilities from
the 3 provinces of Pakistan, including Sindh, Khyber
Pakhtunkhwa, and Punjab. The database started in 2016 at

0002-9149/Published by Elsevier Inc. www.ajconline.org

https://doi.org/10.1016/j.amjcard.2022.11.020
62 The American Journal of Cardiology (www.ajconline.org)
the Tabba Heart Institute, and with the collaborative efforts
of the Pakistan Society of Interventional Cardiology and
Health Research Advisory Board, it is expanding. Standard-
ized data collection is ensured at each facility and gathered
every 3 weeks in the CROP registry. Data quality is main-
tained by real-time data checks built into the online data
collection system.
Patients aged >18 years with coronary artery disease
(CAD) who underwent coronary intervention at CROP
operating facilities during 2016 to 2019 were included in
this study.
Our outcomes of interest of this study included in-hospi-
tal mortality (primary outcome), hematoma, and any bleed-
ing complications after PCI. Hematoma was defined as
≥5 cm of blood collection at the percutaneous entry site
within 72 hours of PCI.8,9 Likewise, bleeding complication
was defined as a decrease in hemoglobin ≥4 g/100 ml or
blood transfusion or intervention to stop or reverse bleeding
within 72 hours of the procedure.8 Data were also extracted
on patients’ demographic characteristics, history of co-mor-
bidities, procedural characteristics and signs, and symptoms
at presentation and were used as explanatory variables.
We report baseline characteristics for all variables in the
form of frequency (percentage) for categorical variables
and mean § SD for quantitative variables. Chi-square/
Fischer’s exact tests and independent sample Student’s t
test were used to assess the difference between categorical
and quantitative variables between men and women. After
evaluating raw frequencies, we performed multivariable
logistic regression to determine whether the female gender
was independently associated with in-hospital mortality
(primary outcome), hematoma, and bleeding complications.
For each of the regression analyses, a prespecified set of
baseline variables including age, hypertension, diabetes
mellitus, use of tobacco, history of cerebrovascular accident
(CVA), previous myocardial infarction (MI), and ST-eleva-
tion MI (STEMI) were added into the model. These varia-
bles were selected based on significance on univariate
analysis and their clinical significance. We also performed
sensitivity analyses in patients with premature CAD (those
aged <50 years). There were sufficient numbers of out-
comes in the overall model to adjust for baseline factors;
however, in the premature group, the model was statisti-
cally less robust because of the lower numbers of outcomes.
Crude and adjusted odds ratios (ORs), along with 95% con-
fidence intervals (CIs) were reported for the covariates in
each multivariable regression model.
To account for the baseline differences between men and
women, we also performed propensity score matching as
part of the sensitivity analyses. The following covariates
were matched between men and women: age, tobacco use,
previous heart failure, family history of premature CAD,
dyslipidemia, hypertension, diabetes mellitus, peripheral
arterial disease, previous CVA, previous MI, previous PCI,
previous coronary artery bypass grafting, previous valve
surgery, currently on dialysis, coronary angiography find-
ings, left main artery disease, right CAD, left anterior
descending artery disease, left circumflex artery disease,
disease in ramus intermedius, and PCI indication. The 2
groups of men and women were matched 1:1 using a caliper
of 0.02, resulting in the successful matching of 5,904
patients (2,952 in each group). Once the 2 groups were well
matched, we evaluated whether the primary outcome (in-
hospital mortality) was significantly different between the 2
groups.
Ethical approval was obtained from the Tabba Heart
Institute Institutionalized Review Board: THI/IRB/SQ/10-
11-2021/091.
Results
Our results included 15,106 patients from the CROP
CathPCI database. Of these, 12,150 were men (80.4%) and
2,956 were women (19.6%). Baseline characteristics by
gender are described in Table 1. Women were significantly
older than men (mean age = 57.3 vs 54.4 years). Traditional
risk factors, including hypertension (72.8% vs 56.4%), dia-
betes (49.3% vs 32.6%), history of CVA (1.2% vs 0.8%),
and peripheral arterial disease (1.5% vs 1.0%) were more
prevalent in women than in men (p <0.05). In contrast,
tobacco use (36.9% vs 6.9%), history of MI (27.1% vs
20.8%), previous PCI (8.9% vs 6.7%), and family history of
premature CAD (16.2% vs 14.5%) were more frequent in
men than in women (p <0.05 for all). No significant differ-
ences were noted between men and women in terms of the
history of heart failure, dyslipidemia, previous coronary
artery bypass grafting or valve surgery, dialysis, atrial fibril-
lation/flutter, and chronic lung disease (p >0.05 for all).
Coronary angiography findings showed that women
were more likely to have more nonobstructive or single-
vessel disease, whereas men were more likely to have 2- or
3-vessel disease; however, the difference was not signifi-
cant (p >0.05). PCI indications did not significantly differ
between men and women (p >0.05).
Table 2 describes periprocedural and postprocedural out-
comes among men and women. Significantly higher unad-
justed in-hospital mortality was noted in women (1.7%)
than in men (1.1%) (p <0.05). The need for coronary artery
bypass grafting after PCI and dialysis were significantly
more in men than in women (p <0.05). Hemodynamic
instability during or after PCI was more common in women
(8.4%) than in men (6.2%). Similarly, overall bleeding
complications (1.2% vs 0.4%), access site hematoma (2%
vs 0.6%), and the need for transfusion (1% vs 0.5%) were
also more frequent in women. The need for intra-aortic bal-
loon pump, coronary perforation, cardiac arrest, arrhyth-
mias, cardiogenic shock, periprocedural MI, stroke, stent
thrombosis, gastrointestinal, genitourinary, and retroperito-
neal bleeding did not significantly differ between women
and men (p >0.05) (Table 2, Figure 1).
Although unadjusted in-hospital mortality was higher in
women than men (1.6, 1.1 to 2.2), this association became
nonsignificant after the adjustment. In the multivariable-
adjusted models (Table 3), in-hospital mortality was com-
parable between men and women (OR: 1.2, 95% CI: 0.8 to
1.7) after adjusting for age, presence of diabetes mellitus,
presence of hypertension, history of CVA, and STEMI at
presentation (Table 3).
After propensity score matching, the baseline variables
were well balanced between the groups (Supplementary
Table 1). We successfully matched 5,904 patients (2,952 in
each group of men and women). The odds of in-hospital
 Coronary Artery Disease/Gender Differences in Outcomes After PCI 63

Table 1
Comparison of baseline characteristics between men and women
Characteristics Women Men p Value
n (%) n (%)
2956 (19.6%) 12150 (80.4%)
Age* 57.3 § 10.56 54.4§10.7 <0.001
Tobacco use 205 (6.9%) 4478 (36.9%) <0.001
Prior heart failure 95 (3.2%) 291 (2.4%) NS
Family history of premature CAD 427 (14.5%) 1967 (16.2%) <0.001
Dyslipidemia 600 (20.3%) 2524 (20.8%) NS
Hypertension 2151 (72.8%) 6856 (56.4%) <0.001
Diabetes mellitus 1456 (49.3%) 3962 (32.6%) <0.001
Peripheral arterial disease 43 (1.5%) 123 (1%) 0.04
Prior cerebrovascular accident 34 (1.2%) 92 (0.8%) 0.04
Prior MI 615 (20.8%) 3291 (27.1%) <0.001
Prior PCI 197 (6.7%) 1079 (8.9%) <0.001
Prior CABG 52 (1.8%) 278 (2.3%) NS
Prior valve surgery 16 (0.5%) 48 (0.4%)
Currently on dialysis 17 (0.6%) 81 (0.7%) NS
Coronary angiography
None 52 (1.8%) 170 (1.4%) NS
Single vessel 1458 (49.3%) 5775 (47.5%)
2 vessels 927 (31.3%) 2230 (18.4%)
3 vessels 519 (17.6%) 3975 (32.7%)
Left main artery disease 50 (1.7%) 249 (2.1%) NS
Right coronary artery disease 1343 (45.4%) 5515 (45.4%) NS
Left anterior descending artery disease 1504 (50.9%) 6239 (51.4%) NS
Left circumflex artery disease 1102 (37.3%) 4706 (38.7%) NS
Disease in ramus intermedius 33 (1.1%) 329 (2.7%) <0.001
PCI indication
Immediate STEMI 410 (14%) 1893 (15.7%) NS
STEMI unstable >12 hours 45 (1.5%) 231 (1.9%)
STEMI stable >12 hours 536 (18.3%) 2091 (17.3%)
STEMI stable after thrombolytic 68 (2.3%) 317 (2.6%)
After failed thrombolytic 18 (0.6%) 95 (0.8%)
NSTEMI/unstable angina 1426 (48.7%) 5767 (47.7%)
Staged PCI 106 (3.6%) 362 (3.0%)
Other 321 (11.0%) 1332 (11.0%)
CABG = coronary artery bypass graft; CAD = coronary artery disease; MI = myocardial infarction; NS = nonsignificant; NSTEMI = non-ST elevation myo-
cardial infarction; PCI = percutaneous coronary intervention; STEMI = ST elevation myocardial infarction.
* Mean § standard deviation.

mortality in the propensity matched sample remained non-
significant between men and women (OR 1.3, 95% C: 0.9
to 2.0).
Age and women gender were independently associated
with post-PCI bleeding complications and hematoma at the
access site (Table 3).
Premature CAD (<50 years)
Traditional risk factors, such as hypertension (66.1% vs
49.2%), diabetes (43.3% vs 26.4%), and previous heart fail-
ure (3.7% vs 2.3%), were more common in young women
than in young men (p <0.001). In contrast, tobacco use and
previous MI were more prevalent in men than in women (p
<0.001). Significant differences were seen in PCI indication
between men and women; STEMI (immediate, unstable,
stable) was common in men, whereas non-STEMI was
common in women (p <0.001). No significant differences
were seen between men in women regarding other baseline
characteristics (Table 4).
There was no significant difference in immediate in-hos-
pital mortality between men and women (0.6% vs 0.6%,
p >0.05). Post-PCI complications, including perforation,
hemodynamic instability, hematoma at the access site, and
bleeding complications, were comparable between men and
women aged <50 years (p >0.05) (Figure 1).
History of CVA (13.7, 1.5 to 127.6) and STEMI (9.9, 3.8
to 25.6) at presentation were independently associated with
in-hospital mortality in patients aged <50 years (Table 5).
Female gender was not significantly associated with in-hos-
pital mortality (1.8, 0.5 to 5.9) or bleeding complications
(2.0, 0.3 to 11.2) in the multivariable-adjusted models;
however, it was associated with access site hematoma
because women were 6.8 times (1.7 to 27.2) more likely to
develop hematoma at the access site than men.
Discussion
In the present study, we found a higher in-hospital mor-
tality in women than in men. This increase in mortality
could be explained by baseline differences between men
and women. In the risk-adjusted analysis, women were
twice as likely to have post-PCI bleeding complications and
thrice as likely to have hematoma at the access site.
64 The American Journal of Cardiology (www.ajconline.org)

Table 2
Comparison of periprocedural and postprocedural mortality and complications between women and men
Characteristics Women Men p Value
n (%) n (%)
2956 (19.6%) 12150 (80.4%)
In-hospital mortality 50 (1.7%) 132 (1.1%) <0.001
Need for intra-aortic balloon pump 6 (0.7%) 20 (0.6%) NS
Coronary dissection during PCI 59 (2.1%) 212 (1.8%) NS
Coronary perforation during PCI 7 (0.2%) 28 (0.2%) NS
Abrupt coronary artery closure 13 (0.5%) 40 (0.3%) NS
No reflow during PCI 88 (3.1%) 306 (2.6%) NS
Hemodynamic instability during or after PCI 65 (8.4%) 174 (6.2%) 0.03
Arrhythmias during or after PCI 34 (1.4%) 119 (4.2%) NS
Cardiac arrest during or after PCI 20 (2.6%) 61 (2.2%) NS
Need for CABG 6 (0.2%) 66 (0.5%) 0.02
Cardiogenic shock during or after PCI 37 (2.9%) 112 (2.3%) NS
Stent thrombosis 5 (0.3%) 16 (0.2%) NS
Periprocedural myocardial infarction 5 (0.3%) 26 (0.5%) NS
Need for dialysis after PCI 1 (0.1%) 23 (0.5%) 0.04*
Stroke after PCI 3 (0.1%) 3 (0.02%) NS*
Cardiac Tamponade 1 (0.1%) 5 (0.1%) NS*
Bleeding within 72 hours of the PCI 23 (1.2%) 34 (0.4%) <0.001
Need for blood transfusion after PCI 21 (1%) 38 (0.5%) <0.001
Access site hematoma after PCI (within 72 hours) 40 (2%) 50 (0.6%) <0.001
NS = nonsignificant p >0.05; PCI = percutaneous coronary intervention.
* Fischer’s exact test.

The unadjusted in-hospital mortality during or after PCI
was significantly higher in women than in men; however,
after adjusting for age, diabetes, hypertension, peripheral
arterial disease, history of CVA, and STEMI at presenta-
tion, the in-hospital mortality became comparable. The
findings of our study extend to the results of other studies.
Data from 8,771 patients who underwent PCI in the registry
of Blue Cross Blue Shield of Michigan Cardiovascular
Consortium showed higher unadjusted in-hospital mortality
(OR 1.8, 95% CI 1.5 to 2.2) in women, but after adjusting
for risk factors, no difference was seen between both gender
in early mortality.10 Studies from United States and

Figure 1. Comparison of clinical outcomes between men and women with CAD and premature CAD. CABG = coronary artery bypass grafting.
 Coronary Artery Disease/Gender Differences in Outcomes After PCI 65

Table 3
Factors associated with in-hospital mortality, bleeding complications, and hematoma at access site after multivariable logistic regression analyses
Characteristics In-hospital mortality Bleeding complications Hematoma at access site
AOR (95% CI) (within 72 hours of PCI) AOR (95% CI)
AOR(95% CI)
Women 1.2 (0.8−1.7) 2.6 (1.4−4.5)* 2.8 (1.8−4.5)*
Age 1.04 (1.03−1.05)* 1.04 (1.01−1.07)* 1.04 (1.02−1.06)*
Hypertension 1.5 (1.1−2.1)* 1.1 (0.6−2.1) 0.8 (0.5−1.3)
Tobacco use 0.9 (0.6−1.4) 1.1 (0.6−2.1) 0.8 (0.4−1.4)
Diabetes mellitus 1.6 (1.2−2.2)* 1.04 (0.6−1.8) 0.9 (0.6−1.4)
Prior CVA 3.5 (1.6−7.6)* 3.2 (0.7−2.4) 1.05 (0.1−7.6)
Prior MI 0.8 (0.5−1.2) 1.3 (0.7−2.4) 1.1 (0.6−1.7)
STEMI at presentation 5.3 (3.8−7.4)* 1.28 (0.7−2.4) 0.7 (0.4−1.2)
AOR = adjusted odds ratio; CI = confidence interval; CVA = cerebrovascular accident; MI = myocardial infarction; STEMI = ST elevation myocardial
infarction.
* Significant (p <0.05).

Germany replicated similar results.4,11,12 Gender-related
differences in unadjusted in-hospital mortality during or
after PCI, as hypothesized by various studies, can be due to
the older age of women at presentation and increased bur-
den of modifiable risk factors, including diabetes and
hypertension.13,14 This was also observed in our study
because women were significantly older than men and had
a higher burden of modifiable risk factors. In addition, after
propensity score matching, the difference in-hospital mor-
tality between men and women remained nonsignificant.
In the SA context, there might be other sociocultural fac-
tors that can influence the difference in mortality between
men and women. Possible factors include delayed treat-
ment, limited access to healthcare, and health-seeking

Table 4
Comparison of baseline characteristics of men and women with premature coronary artery disease (<50 years) (n = 4481)
Characteristics Women Men p Value
n (%) n (%)
631 (14.1%) 3850 (85.9%)
Age* 42.7 § 5.1 42.3 § 5.3 NS
Tobacco use 61 (9.7%) 1731 (45.0%) <0.001
Prior heart failure 23 (3.7%) 89 (2.3%) 0.04
Family history of premature CAD 117 (18.5%) 842 (21.9%) NS
Dyslipidemia 106 (16.8%) 730 (19.0%) NS
Hypertension 417 (66.1%) 1894 (49.2%) <0.001
Diabetes mellitus 273 (43.3%) 1015 (26.4%) <0.001
Peripheral arterial disease 9 (1.4%) 32 (0.8%) NS
Prior cerebrovascular accident 2 (0.3%) 16 (0.4%) NSy
Prior MI 155 (24.6%) 1212 (31.5%) <0.001
Prior PCI 27 (4.3%) 231 (6%) NS
Prior CABG 7 (1.1%) 28 (0.7%) NS
Prior valve surgery 2 (0.3%) 12 (0.3%) NSy
Currently on dialysis 1 (0.2%) 19 (0.5%) NSy
Coronary angiography
None 6 (1.0%) 39 (1.0%) NS
Single vessel 358 (56.7%) 2125 (55.2%)
2 vessels 179 (28.3%) 1105 (28.7%)
3 vessels 88 (14.0%) 581 (15.1%)
Left main artery disease 12 (1.9%) 37 (1.0%) 0.04
Right coronary artery disease 237 (37.6%) 1578 (40.0%) NS
Left anterior descending artery disease 329 (52.1%) 1917 (50.0%) NS
Left circumflex artery 207 (32.8%) 1269 (33.0%) NS
Disease in ramus intermedius 7 (1.1%) 96 (2.5%) 0.03
PCI indication
Immediate STEMI 64 (10.2%) 630 (16.4%) <0.001
STEMI unstable >12 hours 9 (1.4%) 63 (1.6%)
STEMI stable >12 hours 97 (14.5%) 427 (11.1%)
STEMI stable after thrombolytic 16 (2.6%) 124 (3.2%)
After failed thrombolytic 6 (1%) 27 (0.7%)
NSTEMI/unstable angina 357 (56.9%) 2112 (55.0%)
Staged PCI 17 (2.7%) 110 (3.0%)
Other 57 (10.7%) 346 (9.0%)
CABG = coronary artery bypass graft; CAD = coronary artery disease; MI = myocardial infarction; NS = nonsignificant p >0.05; NSTEMI = non-ST-eleva-
tion myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST-elevation myocardial infarction.
* Mean § standard deviation.
y
Fischer’s exact test.
66 The American Journal of Cardiology (www.ajconline.org)
Table 5
Factors associated with in-hospital mortality, bleeding complications, and hematoma at access site in patients with premature CAD (<50 years of age) after
multivariable logistic regression analyses.
Characteristics In-hospital mortality
AOR (95% CI)
Female 1.8 (0.5−5.9)
Age 1.0 (0.9−1.1)
Hypertension 1.1 (0.4−2.6)
Tobacco use 2.1 (0.9−5.1)
Diabetes mellitus 0.8 (0.3−2.2)
Prior CVA 13.7 (1.4−127.5)*
Prior MI 1.3 (0.4−3.3)
STEMI at presentation 9.9 (3.8−25.6)*
AOR = adjusted odds ratio; CI = confidence interval; CVA = cerebrovascular accident; MI = myocardial infarction; STEMI = ST-elevation myocardial
infarction.
* Significant (p <0.05).
barriers. Gender inequities are deeply rooted and extensive
gaps exist in education and healthcare, and nutrition.15,16
The gender disparity that occurs in the healthcare system
also stems from healthcare-seeking behaviors.17 Unless
there is a severe life-threatening situation, women generally
are not taken to healthcare facilities, resulting in delayed
treatment and increased risk of worst outcomes.17 The fam-
ily usually governs decisions regarding women in SA set-
tings; hence, in most households, women don’t have the
autonomy to go to the hospital and seek medical help for
themselves, leading to the loss of valuable hours in which
lives can be saved.18 However, further studies are needed to
explore the relevance and the relative contribution of vari-
ous sociocultural factors in determining differences
between men and women.
In the younger age subsample, previous studies reported
higher unadjusted and adjusted in-hospital mortality in
women than in men (aged ≤55 years),4,6 but our study find-
ings suggest comparable in-hospital mortality in men and
women aged <50 years, supporting the premise that age
indeed is a major determinant of in-hospital mortality in
both genders.
We found an increased risk of post-PCI complications,
predominantly bleeding and access site hematoma in
women compared with men in both univariate and multivar-
iable analyses. This finding is aligned with previous studies
that suggested a higher rate of bleeding complications in
women than men across all ages.19,20 The differences in the
use of anticoagulants or antiplatelets, platelet biology,
congestive heart failure, and hypotension might explain this
disparity;4,21 however, these factors were not explored in
our study. Various studies have suggested a 3- to 10-fold
increase in early mortality because of post-PCI bleeding,
which might also explain the higher unadjusted mortality in
women in our study.21,22 The difference in bleeding compli-
cation was not found in the younger subsample in both risk
the unadjusted and adjusted analyses. These findings con-
trast with previous studies because several single- and mul-
ticenter studies suggested increased peri- and post-PCI
vascular and bleeding complications in women compared
with men in the younger age group.4,23,24 The difference
between young men and women in access site hematoma
Bleeding complications Hematoma at
(within 72 hours of PCI) access site
AOR(95% CI) AOR (95% CI)
2.0 (0.3−11.2) 6.8 (1.7−27.2)*
1.1 (0.9−1.3) 1.04 (0.9−1.1)
2.8 (0.5−14.5) 0.3 (0.07-1.1)
1.1 (0.2−5.0) 2.6 (0.7−10.0)
0.6 (0.1−3.1) 0.5 (0.1−2.6)
- -
2.6 (0.6−11.1) 1.7 (0.5−5.7)
1.3 (0.2−6.9) 0.3 (0.03−2.5)
was seen in the risk-adjusted analysis but data are scarce to
compare this finding from our study. Because most of the
PCI procedures in Pakistan are performed using a femoral
approach, strategies geared toward a higher uptake of PCI
using a radial approach could narrow this gender gap in
bleeding outcomes.
Given the observational nature of our analyses, our study
has limitations. The unavailability of some important varia-
bles, including symptom onset-to-presentation time, door-
to-balloon time, and use of anticoagulants precluded further
assessment of determinants of mortality and bleeding com-
plications in our study. Variability in data reporting by par-
ticipating centers across Pakistan, and underestimating or
overestimating co-morbidities because of inadequate
screening protocols or data capture cannot be ruled out.
The strength of our analyses includes the inclusion of
data from 3 provinces of Pakistan. The findings can be gen-
eralizable to other developing countries of South Asia
because these provide insight into the gender differences in
PCI outcomes in resource-limited settings. The large sam-
ple size from the CROP CathPCI Registry is another
strength of this study.
Conclusion
Higher in-hospital mortality was seen in women; how-
ever, the mortality was comparable between men and
women after adjusting for baseline risk factors and co-mor-
bidities. Crude and adjusted post-PCI complications, pre-
dominantly bleeding, and access site hematoma were more
frequent in women than men. There was no significant dif-
ference in early mortality and complications between men
and women in the younger age group except for access site
hematoma. The findings of the study will help guide
patients and clinicians to make appropriate decisions and
develop quality improvement initiatives to improve clinical
outcomes.
Disclosures
The authors have no conflicts of interest to declare.
 Coronary Artery Disease/Gender Differences in Outcomes After PCI
Acknowledgments
The authors would like to acknowledge PharmEvo Pri-
vate Limited for their logistic support in the CROP (Cardiac
Registry of Pakistan) registry.
Supplementary materials
Supplementary material associated with this article can
be found in the online version at https://doi.org/10.1016/j.
amjcard.2022.11.020.
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