# Sex-Based Differences in Long-Term Outcomes Following Percutaneous Coronary Intervention for Chronic Total Occlusions

## TL;DR

This study found that while women and men have similar overall outcomes after a specific heart procedure, women face a higher risk of heart attacks in the long term.

## Contribution

The study identifies sex-based differences in long-term outcomes following CTO-PCI using a real-world cohort and adjustment for baseline differences.

## Key findings

- Women had higher unadjusted MACE rates but similar rates after adjustment.
- Women had a significantly higher risk of MI after adjustment.
- Technical and procedural success rates were comparable between sexes.

## Abstract

Background/Objectives: Sex-based differences in clinical profiles and outcomes following percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remain poorly understood. We sought to examine the association between sex and long-term clinical outcomes following CTO-PCI in a contemporary real-world cohort. Methods: We conducted a retrospective study of 928 consecutive patients (788 men, 140 women) undergoing CTO-PCI at a high-volume centre between 2011 and 2024. The primary endpoint was a composite of major adverse cardiac events (MACE: all-cause death, myocardial infarction [MI], or stroke) at a 6-year follow-up. To account for baseline differences, an Inverse Probability of Treatment Weighting (IPTW)-adjusted Cox regression analysis was performed. Results: Women were significantly older (69.7 ± 10 vs. 64.1 ± 10 years; p < 0.001) and had a higher prevalence of diabetes and hypertension. However, women exhibited lower angiographic complexity, with lower J-CTO scores (2 [1–2] vs. 2 [1–3]; p < 0.001) and less frequent severe calcification or tortuosity. Technical and procedural success rates were comparable between sexes (85.4% vs. 86.7%; p = 0.695). Unadjusted MACE rates were higher in women (29.3% vs. 22.1%; hazard ratio (HR) 1.51, 95% CI: 1.08–2.13; p = 0.017). After adjustment, the female sex was no longer associated with the primary endpoint (aHR 1.15, 95% CI: 0.76–1.74; p = 0.517), but the risk of MI remained significantly higher in this group (aHR 2.85, 95% CI: 1.23–6.63; p = 0.015). Conclusions: CTO-PCI appeared to be equally safe and effective in women and men. Over long-term follow-up, although the overall adjusted MACE risk was similar between sexes, the female sex was associated with a higher risk for MI.