Impact of Gender on Arterial Revascularization Strategies for Coronary Artery Bypass Grafting

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

METHODS

We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

RESULTS

Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

CONCLUSIONS

Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Single versus multiple arterial coronary artery bypass grafting in men and women: results from Polish National Registry of Cardiac Surgery Procedures

BACKGROUND

The objective of this multicenter study aimed to investigate the impact of sex on long-term survival among patients with multivessel coronary artery disease undergoing coronary artery bypass grafting (CABG) using multiple arterial grafting (MAG) or a single artery with saphenous vein grafts.

MATERIALS AND METHODS

Data were obtained from the Polish National Registry of Cardiac Surgery Procedures database. This study included 81 136 patients who underwent CABG for multivessel disease between January 2012 and December 2020 (22.9 were women and 77.1% were men). MAG was performed in 8.3 and 11.7% of female and male patients, respectively. A 1:1 propensity score (PS)-matching was performed. Long-term mortality was compared between matched groups of men and women. Subgroup analyses of patients aged <70 and ≥70 years, with an ejection fraction (EF) >40% and ≤40%, and with and without diabetes, obesity, peripheral artery disease (PAD), or chronic lung disease (CLD) were performed separately in women and men.

RESULTS

MAG was associated with lower long-term mortality than saphenous vein grafts in 1528 PS-matched female pairs [hazard ratio (HR): 0.74; 95% CI: 0.59-0.92; P =0.007) and 7283 PS-matched male pairs (HR: 0.80; 95% CI: 0.72-0.88; P <0.001). Subgroup analyses confirmed the results among female patients aged <70 years, with diabetes and EF >40%, and without PAD or CLD, and of male patients aged <70 and ≥70 years; with EF >40%; with or without diabetes, obesity, or PAD; and without CLD.

CONCLUSIONS

In patients undergoing CABG, MAG was associated with significantly improved survival in both sexes. The long-term benefits of MAG observed across subgroups of men and women support the consideration of a multiarterial revascularization strategy for a broader spectrum of patients.

Impact of sex on outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

BACKGROUND

The impact of sex on long-term outcomes after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (PH) remains unclear. We therefore examined the early and long-term outcome after PEA to determine whether sex had an impact on the risk of residual PH and need for targeted PH medical therapy.

METHODS

Retrospective study of 401 consecutive patients undergoing PEA at our institution between August 2005 and March 2020 was performed. Primary outcome was the need for targeted PH medical therapy postoperatively. Secondary outcomes included survival and measures of hemodynamic improvement.

RESULTS

Females (N = 203, 51%) were more likely to have preoperative home oxygen therapy (29.6% vs 11.6%, p < 0.01), and to present with segmental and subsegmental disease compared to males (49.2% vs 21.2%, p < 0.01). Despite similar preoperative values, females had higher postoperative pulmonary vascular resistance (final total pulmonary vascular resistance after PEA, 437 Dynes∙s∙cm-5 vs 324 Dynes∙s∙cm-5 in males, p < 0.01). Although survival at 10 years was not significantly different between sexes (73% in females vs 84% in males, p = 0.08), freedom from targeted PH medical therapy was lower in females (72.9% vs 89.9% in males at 5 years, p < 0.001). Female sex remained an independent factor affecting the need for targeted PH medical therapy after PEA in multivariate analysis (HR 2.03, 95%CI 1.03-3.98, p = 0.04).

CONCLUSIONS

Although outcomes are excellent for both sexes, females had greater need for targeted PH medical therapy in the long-term. Early reassessment and long-term follow-up of these patients are important. Further investigations into possible mechanisms to explain the differences are warranted.

Systemic Immune-Inflammation Index Predicts Prolonged Mechanical Ventilation and Intensive Care Unit Stay After off-Pump Coronary Artery Bypass Graft Surgery: A Single-Center Retrospective Study

Purpose

Coronary artery disease (CAD) is the primary cause of mortality in developing countries. Off-pump coronary artery bypass grafting (OPCAB) offers more upside in revascularization by preventing cardiopulmonary bypass trauma and minimizing aortic manipulation. Even though cardiopulmonary bypass is not involved, OPCAB still causes a significant systemic inflammatory response. This study determines the prognostic values of the systemic immune-inflammation index (SII) towards perioperative outcomes in patients who underwent OPCAB surgery.

Patients and methods

This was a single-center retrospective study at the National Cardiovascular Center Harapan Kita, Jakarta, using secondary data from electronic medical records and medical record archives of all patients who underwent OPCAB from January 2019 through December 2021. A total of 418 medical records were obtained, and 47 patients were excluded based on the exclusion criteria. The values of SII were calculated from preoperative laboratory data of segmental neutrophil count, lymphocyte count, and platelet count. Patients were divided into two groups based on the SII cutoff value of 878.056 x 10³/mm³.

Results

The baseline SII values of 371 patients were calculated, among which 63 (17%) patients had preoperative SII values of ≥878.057 x 10³/mm³. High SII values were a significant predictor of prolonged ventilation (RR 1.141, 95% CI 1.001-1.301) and prolonged ICU stay (RR 1.218, 95% CI 1.021-1.452) after OPCAB surgery. A positive correlation was observed between SII and hospital length of stay after OPCAB surgery. From the receiver operating characteristic curve analysis, SII predicted prolonged ventilation duration, with an area under the curve of 0.658 (95% CI 0.575-0.741, p = 0.001).

Conclusion

High preoperative SII values are capable of predicting prolonged mechanical ventilation and intensive care unit stay after OPCAB surgery.

Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7

Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.

Sex-Specific Considerations in the Presentation, Diagnosis, and Management of Ischemic Heart Disease: JACC Focus Seminar 2/7

There are sex-related differences in the epidemiology, presentation, diagnostic testing, and management of ischemic heart disease in women compared with men. The adjusted morbidity and mortality are persistently higher, particularly in younger women and Blacks. Women have more angina but less obstructive coronary artery disease, which affects delays in presentation and diagnosis and testing accuracy. The nonbiological factors play a significant role in access to care, ischemic heart disease management, and guideline adherence. Future research focus includes sex-specific outcomes, characterization of the biological differences, and implementation science around quality of clinical care.

A COMPARISON OF AKIN, KDIGO AND RIFLE DEFINITIONS TO DIAGNOSE ACUTE KIDNEY INJURY AND PREDICT THE OUTCOMES AFTER CARDIAC SURGERY IN A SOUTH ASIAN COHORT

BACKGROUND

Acute kidney injury (AKI) after cardiac surgery is associated with an increased mortality and morbidity. Different definitions for AKI have been used such as Acute Kidney Injury Network (AKIN), Kidney Disease: Improving Global Outcomes (KDIGO) or risk, injury, failure, loss, end-stage kidney disease (RIFLE). Each of these definitions have their own benefits and limitations for predicting the degree of AKI and adverse outcomes following cardiac surgery. This study was aimed to compare the three AKI definitions to diagnose AKI and their predictive ability for mortality and morbidity after isolated coronary artery bypass surgery (CABG) in a South Asian cohort.

MATERIAL AND METHODS

A single center retrospective review was conducted on 1508 patients having undergone isolated CABG surgery during January 2015 to January 2019. AKI was assessed on three definitions and comparative receiver operating characteristics curves were built against the outcomes to assess discriminative power of each.

RESULTS

Mean age of participants was 59.43 (±1.12) years, predominantly males (82.6%). Patient with AKI were elder, more likely to be diabetic and hypertensive. AKI by any definition occurred in 58.7% (885/1508) patients. Frequency of AKI was 508 (33.7%), 517 (34.4%) and 871 (57.8%) on AKIN, KDIGO and RIFLE criteria, respectively. The proportion of patients with RIFLE- risk 619 (41%) was greater compared with AKIN stage 1 [342 (22.7%)], and KDIGO stage 1 [330 (21.9%)], while for stage 2 and 3 the proportions were comparable across the three systems. Area under the curve (AUC) for 30-day mortality for AKIN was [0.786, (95% CI: 0.764 to 0.806)], KDIGO: [0.796, (95% CI: 0.775 to 0.816)], and for RIFLE [0.844, (95% CI: 0.825 to 0.862)]. AUC for overall morbidity were in undesirable ranges (i.e. >0.5 to ≤ 0.7) for all three definitions.

CONCLUSION

In a South Asian cohort, performance of AKIN and KDIGO criteria was comparable to diagnose AKI, while RIFLE definition, though overestimated the incidence of AKI particularly stage 1, and had an excellent discriminatory power to predict mortality compared to other two definitions.

Sex disparities in in-hospital outcomes of left ventricular aneurysm complicating acute myocardial infarction: A United States nationwide analysis

Background

Previous studies have reported sex-specific differences in the presentation, mechanisms, and outcomes of acute myocardial infarction (AMI). We assessed differences between women and men in the incidence and in-hospital outcomes of left ventricular (LV) aneurysm complicating AMI.

Methods

Hospitalizations for AMI with LV aneurysm were identified retrospectively in the National Inpatient Sample (NIS) from 2001 to 2017. Incidence and trends in in-hospital mortality, complications, length of stay and costs were analyzed in women and men.

Results

A total of 16,334 AMI hospitalizations with concomitant LV aneurysm were identified including 6994 (42.8%) women and 9340 (57.2%) men. Among these hospitalizations, women had a higher incidence of LV aneurysm compared to men (0.16% vs. 0.14%; p < 0.001). Unadjusted in-hospital mortality was higher in women than men (12.7% vs. 7.2%; p < 0.001). After adjusting for demographic and baseline characteristics and excluding inter-hospital transfers, women with AMI complicated by LV aneurysm had 49% greater odds of in-hospital mortality than men (OR 1.49, 95% confidence interval 1.06-2.10, p = 0.02). Women with LV aneurysm were less likely than men to undergo percutaneous coronary intervention (28.5% vs. 35.4%; p < 0.001), bypass surgery (15.8% vs. 25.1%; p < 0.001), coronary atherectomy (0.8% vs. 1.9%; p = 0.009) and LV aneurysm surgery (7.8% vs. 11.1%; p = 0.001).

Conclusions

In this large population-based cohort study, women had a slightly higher incidence but dramatically higher in-hospital mortality associated with LV aneurysm complicating AMI compared to men. Further research is necessary to validate strategies to ensure that women receive guideline-directed therapy for AMI and LV aneurysm to address the sex disparity in mortality.

Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care?

Cardiovascular disease remains the leading cause of morbidity and mortality for women in United States and worldwide. One in 3 women dies from cardiovascular disease, and 45% of women >20 years old have some form of CVD. Historically, women have had higher morbidity and mortality after cardiac surgery. Sex influences pathogenesis, pathophysiology, presentation, postoperative complications, surgical outcomes, and survival. This review summarizes current cardiovascular surgery outcomes as they pertain to women. Specifically, this article seeks to address whether sex disparities in research, surgical referral, and outcomes still exist and to provide strategies to close these gaps. In addition, with the growing population of women of reproductive age with cardiovascular disease and cardiovascular risk factors, indications for cardiac surgery arise in pregnant women. The current review will also address the unique issues associated with this special population.

Representation of Women in Randomized Trials in Cardiac Surgery: A Meta-Analysis

Background

Women have traditionally been underrepresented in randomized clinical trials (RCTs). We performed a systematic evaluation of the inclusion of women in cardiac surgery RCTs published in the past 2 decades.

Methods and Results

MEDLINE, EMBASE, and the Cochrane Library were searched (2000 to July 2020) for RCTs written in English, comparing ≥2 adult cardiac surgical procedures. The percentage of women enrolled and its association with year of publication, sample size, mean age, funding source, geographic location, number of sites involved, and interventions tested were analyzed using a meta‐analytic approach. Fifty‐one trials were included. Of 25 425 total patients, 5029 were women (20.8%; 95% CI, 17.6–24.4; range, 0.5%–57.9%). The proportion of women dropped significantly during the study period (29.6% in 2000 versus 13.1% in 2019, P<0.001). Women were significantly more represented in European trials (26.2%; 95% CI, 21.2–31.9), and less represented in trials of coronary bypass surgery versus other interventions (16.8%; 95% CI, 12.3–22.7 versus 33.6%; 95% CI, 27.4–40.5; P=0.0002) and in trials enrolling younger patients (P=0.009); the percentage of women was higher in industry‐sponsored versus non‐industry sponsored trials (31.7%; 95% CI, 27.2–36.6 versus 15.5%; 95% CI, 10.0–23.2; P=0.0004) and was not associated with trial sample size (P=0.52) or study design (multicenter versus monocenter: P=0.22). After exclusion of trials conducted at Veteran Affairs centers, women representation was 24.4% (95% CI, 21.1–28.0; range, 10.4%–57.9%), with no significant changes during the study period.

Conclusions

The proportion of women in cardiac surgery trials is low and likely inadequate to provide meaningful estimates of the treatment effect.

Sex Differences in Coronary Artery Bypass Grafting Techniques: A STS Database Analysis

BACKGROUND

Females with coronary artery disease (CAD) have inferior outcomes compared with males, including higher mortality following coronary artery bypass grafting (CABG). We aimed to evaluate the association of female sex with the use of guideline-concordant CABG revascularization techniques.

METHODS

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for adult patients who underwent first-time isolated CABG in the US from 2011-2019. The association between female sex and the odds of (1) receiving a left internal mammary artery (LIMA) graft for revascularization of the left anterior descending (LAD) artery, (2) undergoing complete revascularization, and (3) undergoing multi-arterial grafting was assessed, adjusting for procedural anatomy.

RESULTS

Among 1,212,487 patients meeting inclusion criteria, 75% were male (n=911,178) and 25% were female (n=301,309). Female sex was associated with lower unadjusted rates of revascularization with an IMA (93.9% vs 95.9%, P<.001), bilateral IMA (2.9% vs 5.6%, P<.001) or radial artery (3.2% vs 5.6%, P<.001) graft. After adjustment, females had a lower odds than males of receiving a LIMA graft to the LAD (adjusted odds ratio [AOR] 0.79, 95% CI 0.75-0.83, P<.001), undergoing complete revascularization (AOR 0.86, 95% CI 0.83-0.90, P<.001), and undergoing multi-arterial grafting (AOR 0.78, 95% CI 0.75-0.81, P<.001).

CONCLUSIONS

Female sex was associated with a 14-22% lower odds of undergoing guideline concordant revascularization including LIMA to LAD grafting, multi-arterial grafting, and complete revascularization. Further investigation is necessary to determine why revascularization approaches differ by sex and to what degree sex disparities in CAD outcomes are due to surgical approach.

Sex differences in health resource utilization, costs and mortality during hospitalization for infective endocarditis in the United States

Background

Few studies have assessed the association between sex and outcomes among patients with infective endocarditis. The aim of the study was to better understand the association between biologic sex, clinical outcomes and surgical treatment patterns among a contemporary cohort of patients admitted to hospital with infective endocarditis.

Methods

We used the National Inpatient Sample dataset from the Health Care Utilization Project to identify adult patients admitted for infective endocarditis between January and December 2016. We compared outcomes between men and women including inpatient hospital mortality, direct hospital costs, length of stay, and inpatient surgical treatment patterns. Multivariable analyses were performed with adjustment for age, socioeconomic status, and comorbidity burden.

Results

Among 18,702 patients with infective endocarditis, there were 8730 (46.7%) women and 1753 (8.4%) in-hospital deaths. In multivariable analysis, female sex was associated with a trend toward lower in-hospital mortality (adjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.80 to 1.01, p = 0.06). Additionally, female sex was associated with significantly shorter hospital length of stay (-0.5 days; 95% CI -0.88 to -0.12, p = 0.009) and lower hospital costs (-$3035; 95% CI -$4277 to -$1792; p < 0.001). Notably, women were less likely to undergo surgical intervention (adjusted OR 0.59; 95% CI 0.52 to 0.67, p < 0.001).

Conclusions

In a contemporary, nationally representative cohort of patients admitted for IE in the United States, there were sex-specific differences in management and in-hospital outcomes. Possible sex-based bias in treatment patterns and access to inpatient surgical intervention for infective endocarditis warrants further study.

Adiponectin and Sarcopenia: A Systematic Review With Meta-Analysis

BACKGROUND

Sarcopenia is a progressive loss of skeletal muscle mass whose pathophysiology has been proposed to possibly involve mechanisms of altered inflammatory status and endocrine function. Adiponectin has been shown to modulate inflammatory status and muscle metabolism. However, the possible association between adiponectin levels and sarcopenia is poorly understood. In order to fill this gap, in the present manuscript we aimed to summarize the current evidence with a systematic review and a meta-analysis of studies reporting serum adiponectin levels in patients with sarcopenia compared to non-sarcopenic controls.

METHODS

An electronic search through Medline/PubMed, Cochrane Library, and Science Direct was performed till March 1, 2020. From the included papers, meta-analysis of cross-sectional studies comparing serum levels of adiponectin between patients with sarcopenia and controls was performed.

RESULTS

Out of 1,370 initial studies, seven studies were meta-analyzed. Sarcopenic participants had significantly higher levels of adiponectin Hedges' g with 95% confidence interval (CI): 1.20 (0.19-2.22), p = 0.02 than controls. Subgroup analysis, performed in Asian population and focused on identification of the condition based on AWGS criteria, reported higher adiponectin levels in sarcopenic population (2.1 (0.17-4.03), p = 0.03 and I2 = 98.98%. Meta-regression analysis revealed female gender to significantly influence the results as demonstrated by beta = 0.14 (95% CI (0.010-0.280), p = 0.040).

CONCLUSIONS

Our meta-analysis found evidence that sarcopenia is associated with higher adiponectin levels. However, caution is warranted on the interpretation of these findings, and future longitudinal research is required to disentangle and better understand the topic.

Differences in Long-term Outcomes After Coronary Artery Bypass Grafting Using Single vs Multiple Arterial Grafts and the Association With Sex

IMPORTANCE

Sex-related differences in the outcome of using multiple arterial grafts during coronary artery bypass grafting (CABG) remain uncertain.

OBJECTIVE

To compare the outcomes of the use of multiple arterial grafts vs a single arterial graft during CABG for women and men.

DESIGN, SETTING, AND PARTICIPANTS

This statewide cohort study used data from New York's Cardiac Surgery Reporting System and New York's Vital Statistics file on 63 402 patients undergoing CABG from January 1, 2005, to December 31, 2014. Statistical analysis was performed from January 10 to August 20, 2020.

EXPOSURES

Multiple arterial grafting or single arterial grafting.

MAIN OUTCOMES AND MEASURES

Mortality, acute myocardial infarction (AMI), stroke, repeated revascularization, major adverse cardiac and cerebrovascular event (composite of mortality, AMI, and stroke), and major adverse cardiac event (composite of mortality, AMI, or repeated revascularization) were compared among propensity-matched patients and stratified by the risk of long-term mortality.

RESULTS

Of the 63 402 patients (48 155 men [76.0%]; mean [SD] age, 69.9 [10.5] years) in the study, women had worse baseline characteristics than men for most of the explored variables. Propensity matching yielded a total of 9512 male pairs and 1860 female pairs. At 7 years of follow-up, mortality was lower among men who underwent multiple arterial grafting (adjusted hazard ratio, 0.80; 95% CI, 0.73-0.87) but not women who underwent multiple arterial grafting (adjusted hazard ratio, 0.99; 95% CI, 0.84-1.15). When stratified by the estimated risk of death, the use of multiple arterial grafts was associated with better survival and a lower rate of a major adverse cardiac event among low-risk, but not high-risk, patients of both sexes, and the risk cutoff was different for men and women.

CONCLUSIONS AND RELEVANCE

This study suggests that women have a worse preoperative risk profile than men. Multiple arterial grafting is associated with better outcomes among low-risk, but not high-risk, patients, and the risk cutoffs differ between sexes. These data highlight the need for new studies on the outcome of multiple arterial grafts in women.

Is gender a risk factor for bilateral internal thoracic artery grafting? A twenty-year follow-up

BACKGROUND

Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique, especially in female patients, due to its greater complexity and potential increased risk of sternal infection. The aim of this study was to compare the outcomes of male and female patients who underwent BITA grafting.

METHODS

We evaluated at the early outcome and late mortality, 551 female versus 2525 male patients who underwent isolated BITA grafting between January 1996 and December 2011. To adjust for differences in demographic and clinical characteristics, a multivariate risk analysis and propensity score matching were performed. Kaplan-Meier analysis was performed for the entire cohort and for the matched cohort.

RESULTS

Female patients were older and were more likely than males to have congestive heart failure, unstable angina pectoris, and diabetes. Sternal infection was more frequent in females than males (3.3% vs. 1.8%; p = .04). Differences were not observed in operative mortality (2.9% vs. 1.9%; p = .15) and stroke incidence (3.4% vs. 2.6; p = .30). After multivariate risk analysis and propensity score matching, the female gender was not found to be a predictor of worse outcomes. There was no difference in median survival among female and male patients (14.3 and 14.2 years, respectively; p = .68).

CONCLUSION

Our results support the routine use of BITA grafting in proper selected female patients who undergo myocardial revascularization.

Multiple arterial coronary bypass grafting is associated with greater survival in women

OBJECTIVE

Multiple arterial grafting (MAG) in coronary artery bypass grafting (CABG) is associated with higher survival and freedom from major adverse cardiac and cerebrovascular events (MACCEs) in observational studies of mostly men. It is not known whether MAG is beneficial in women. Our objectives were to compare the long-term clinical outcomes of MAG versus single arterial grafting (SAG) in women undergoing CABG for multivessel disease.

METHODS

Clinical and administrative databases for Ontario, Canada, were linked to obtain all women with angiographic evidence of left main, triple or double vessel disease undergoing isolated non-emergent primary CABG from 2008 to 2019. 1:1 propensity score matching was performed. Late mortality and MACCE (composite of stroke, myocardial infarction, repeat revascularisation and death) were compared between the matched groups with a stratified log-rank test and Cox proportional-hazards model.

RESULTS

2961 and 7954 women underwent CABG with MAG and SAG, respectively, for multivessel disease. Prior to propensity-score matching, compared with SAG, those who underwent MAG were younger (66.0 vs 68.9 years) and had less comorbidities. After propensity-score matching, in 2446 well-matched pairs, there was no significant difference in 30-day mortality (1.6% vs 1.8%, p=0.43) between MAG and SAG. Over a median and maximum follow-up of 5.0 and 11.0 years, respectively, MAG was associated with greater survival (HR 0.85, 95% CI 0.75 to 0.98) and freedom from MACCE (HR 0.85, 95% CI 0.76 to 0.95).

CONCLUSIONS

MAG was associated with greater survival and freedom from MACCE and should be considered for women with good life expectancy requiring CABG.

Percutaneous coronary intervention in women: is sex still an issue?

Coronary artery disease among women presents differences in terms of clinical presentation and pathophysiology. To date, women present worse prognoses with more events and higher mortality rate. One the one hand, they are less likely addressed for invasive therapy. One the other hand, revascularization procedures, whether by bypass or by percutaneous coronary intervention, are associated with higher rates of complications and poorer prognosis. Despite higher risk factor burden and comorbidity, women are less affected by obstructive disease and plaque characteristics are more favorable than among men. Abnormalities of endothelial function and micro vascular flow reserve could explain part of the high prevalence of symptoms of angina observed among women. Due to the worse prognosis of microvascular dysfunction, particularly in women, proper diagnosis is mandatory and deserve invasive management. Outcome following ST elevation myocardial infarction is still more severe among women with higher in-hospital mortality, but sex discrepancies are observed even in elective percutaneous coronary intervention. However, improvement of techniques, drugs and devices benefited to both men and women and tend to decrease gender gap. Especially, changes in the design of newer-generation drug-eluting stents (DES) may be particularly important for women. Female sex remains a potent predictor of higher risk of bleeding and vascular complication; thus important efforts should be promoted to develop bleeding avoidance strategies. Sex-based differences still deserve dedicated investigations in terms of physiopathology, particular hormonal impacts, and specific responses to drugs and devices.

Gender Differences in Postoperative Outcomes After Cardiac Surgery

Women presenting for cardiac surgery tend to be older and have hypertension, diabetes, and overweight or underweight body mass index than men. Despite improvements in surgical techniques and medications, women have increased risk for morbidity and mortality after multiple types of cardiac surgery. Women presenting for transcatheter aortic valve replacement are older and frailer than men, and have increased risk of intraoperative complications, but lower mortality at mid- and long-term ranges compared with men. Adherence to recovery and rehabilitation from cardiac surgery is challenging for women. Solutions should focus on increased family support, and use of group exercise and activities.

Sex-specific outcome after minimally invasive direct coronary artery bypass for single-vessel disease

OBJECTIVES

Female gender is reported as an independent risk factor for a poor outcome after coronary artery bypass grafting. We analysed the influence of gender on surgical outcome in patients with single-vessel disease undergoing minimally invasive direct coronary artery bypass (MIDCAB).

METHODS

From January 1998 to December 2016, a total of 607 consecutive patients with single-vessel disease (31.9% women) underwent MIDCAB at our institution. Major adverse cardiac and cerebrovascular events (MACCE) were recorded during a median follow-up period of 8.0 years. Survival time was estimated for all patients and after applying propensity score matching (138 women vs 138 men). Multivariable Cox regression analysis identified risk factors predicting a long-term mortality rate.

RESULTS

In women, a longer surgical time (125 vs 113 min; P &lt; 0.001) and a higher transfusion rate were recorded (13.0% vs 5.1%; P = 0.001) with similar rates of in-hospital deaths (1.0% vs 0.5%; P = 0.60) and MACCE (1.5% vs 0.7%; P = 0.39). Survival and MACCE-free survival during the follow-up period did not differ significantly between genders (P = 1.0, P = 0.36). Survival and MACCE-free survival rates after 5 years were 94% and 90% in women compared to 91% and 86% in men. Propensity score matching demonstrated improved long-term survival rates in women (P = 0.029). Insulin-dependent diabetes mellitus, postoperative atrial fibrillation and prolonged intensive care unit stay were associated with long-term deaths for both genders, whereas obesity, former myocardial infarction and preoperative atrial fibrillation were significant risk factors in men.

CONCLUSIONS

Female patients showed no adverse outcomes after MIDCAB, although risk factors were gender-specific. Overall, MIDCAB demonstrated excellent short- and long-term results as a treatment for single-vessel disease in both genders.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Recognition and treatment of ischemic heart diseases in women

Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.

Calculated plasma volume status and outcomes in patients undergoing coronary bypass graft surgery

OBJECTIVES

Congestion is associated with worse outcomes in critically ill surgical patients but can be difficult to quantify noninvasively. We hypothesised that plasma volume status (PVS), estimated preoperatively using a validated formula that enumerates percentage change from ideal plasma volume (PV), would provide incremental prognostic utility after coronary artery bypass graft (CABG) surgery.

METHODS

In this retrospective cohort study, patients who underwent CABG surgery (1999-2010) were identified from a prospectively collected database. Actual ([1-haematocrit] x [a+(b x weight [kg])]) and ideal (c x weight [kg]) PV were obtained from equations where a, b and c are sex-dependent constants. Calculated PVS was then derived (100% x [(actual-ideal)/ideal]).

RESULTS

In 1887 patients (mean age 67±10 years; 79% male; median European System for Cardiac Operative Risk Evaluation [EuroSCORE] 4), mean PVS was -8.2±9%. While 8% of subjects had clinical evidence of congestion, a relatively increased PV (PVS >0%) was estimated in 17% and correlated with lower serum sodium, higher EuroSCORE and a diagnosis of diabetes mellitus. A PVS≥5.6% was optimally prognostic and associated with greater mortality (HR: 2.31, p=0.009), independently of, and incremental to, EuroSCORE, New York Heart Association class and serum sodium. A PVS≥5.6% also independently predicted longer intensive care (β: 0.65, p=0.007) and hospital (β: 2.01, p=0.006) stays, and greater postoperative renal (OR: 1.61, p=0.008) and arrhythmic (OR: 1.29, p=0.03) complications.

CONCLUSIONS

Higher PVS values, calculated simply from weight and haematocrit, are associated with worse inpatient outcomes after CABG. PVS could help refine risk stratification and further investigations are warranted to evaluate the potential clinical utility of PVS-guided management in patients undergoing CABG.

Routine use of bilateral internal thoracic artery grafting in women does not increase in-hospital mortality and could improve long-term survival

BACKGROUND

Bilateral internal thoracic artery (BITA) grafting is underused in women.

METHODS

Outcomes of 798 consecutive women with multivessel coronary disease who underwent isolated coronary surgery (1999-2016) using BITA (n=530, 66.4%) or single internal thoracic artery (SITA) grafting (n=268, 33.6%) were reviewed retrospectively. Differences between BITA and SITA cohort were adjusted by propensity score matching. For both series, late survival was estimated with the Kaplan-Meier method.

RESULTS

One-to-one propensity score matching resulted in 247 BITA/SITA pairs with similar baseline characteristics and risk profile. According to the propensity matching, BITA grafting was associated with a trend towards reduced in-hospital mortality (3.2% vs. 5.7%, p=0.19). However, BITA women had an increased chest tube output (p=0.0076) as well as higher rates of any (13% vs. 5.3%, p=0.003) and deep sternal wound infections (9.3% vs. 4.9%, p=0.054), this translating in a longer in-hospital stay (10 vs. 9days, p=0.029). Test for interaction showed that body mass index >30kg/m² and extracardiac arteriopathy were associated with a higher risk of deep sternal wound infection in BITA than in SITA women (23.4% vs. 13.7%, p<0.001 and 23.9% vs. 3.4%, p=0.001, respectively). Freedom from all-cause death and cardiac or cerebrovascular death were improved in BITA cohort, even though the differences were not quite significant (p=0.16 and 0.076, respectively).

CONCLUSIONS

When routinely performed, BITA grafting does not increase in-hospital mortality in women and could improve long-term survival. However, its use should be avoided in obese women with extracardiac arteriopathy because of increased risk of deep sternal wound infection.

Gender and intraoperative blood transfusion: analysis of 54,122 non-reoperative coronary revascularization procedures

Background:

Previous studies have shown that women undergoing isolated coronary artery bypass graft (CABG) surgery have an increased risk for postoperative morbidity and mortality when compared to men. Additionally, recent evidence suggests that blood transfusions are independently associated with an increased risk of adverse outcome.

Methods:

We evaluated gender differences in the risk of intraoperative red blood cell (RBC) transfusion during CABG surgery. Consecutive, non-reoperative CABG procedures performed across 196 institutions between April 2012 and May 2015 were retrospectively reviewed. Gender differences for intraoperative transfusion were evaluated with a multi-variable binary logistic regression model, adjusting for age, blood volume (Nadler formula to normalize for height and weight), body mass index, procedure acuity, net extracorporeal circuit prime volume, use of autologous priming, first hematocrit (Hct) in the operating room (OR), nadir Hct on cardiopulmonary bypass (CPB), volume added on CPB, ultrafiltration volume, urine output on CPB and procedure duration.

Results:

Among 54,122 patients (25.3% female), 21.6% (n = 11,701) received a RBC transfusion. Compared to men, female patients were older (66 years vs. 64 years, p<0.001), had lower blood volumes (4.3L vs. 5.6L, p<0.001) and a lower preoperative Hct (32.9% vs. 37.2%, p<0.001). Transfusion rates were three-fold higher in women versus men (45.1% vs. 13.7%, p<0.001). After adjustment for independent predictors of intraoperative transfusion, women remained at increased risk versus men (OR = 1.30, 95%CI = 1.19−1.43).

Conclusions:

Women have an increased risk of intraoperative RBC transfusion versus men. After adjusting for height and weight, much of this risk is due to gender differences in preoperative Hct and blood volume; however, a residual significant risk remained after adjustment. Perfusion strategies aimed at gender differences may minimize unnecessary transfusions. Future study on the impact of gender on transfusion practice in cardiac surgery is warranted.

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999-2014

Background

With over a decade of directed efforts to reduce sex and racial differences in coronary artery bypass grafting (CABG) utilization, and post‐CABG outcomes, we sought to evaluate how the use of CABG and its outcomes have evolved in different sex and racial subgroups.

Methods and Results

Using data on all fee‐for‐service Medicare beneficiaries undergoing CABG in the United States from 1999 to 2014, we examined differences by sex and race in calendar‐year trends for CABG utilization and post‐CABG outcomes (in‐hospital, 30‐day, and 1‐year mortality and 30‐day readmission). A total of 1 863 719 Medicare fee‐for‐service beneficiaries (33.6% women, 4.6% black) underwent CABG from 1999 to 2014, with a decrease from 611 to 245 CABG procedures per 100 000 person‐years. Men compared with women and whites compared with blacks had higher CABG utilization, with declines in all subgroups. Higher post‐CABG annual declines in mortality (95% confidence interval) were observed in women (in‐hospital, −2.70% [−2.97, −2.44]; 30‐day, −2.29% [−2.54, −2.04]; and 1‐year mortality, −1.67% [−1.88, −1.46]) and blacks (in‐hospital, −3.31% [−4.02, −2.60]; 30‐day, −2.80% [−3.49, −2.12]; and 1‐year mortality, −2.38% [−2.92, −1.84]), compared with men and whites, respectively. Mortality rates remained higher in women and blacks, but differences narrowed over time. Annual adjusted 30‐day readmission rates remained unchanged for all patient groups.

Conclusions

Women and black patients had persistently higher CABG mortality than men and white patients, respectively, despite greater declines over the time period. These findings indicate progress, but also the need for further progress.

Coronary Surgery in Women and the Challenges We Face

This review was undertaken to understand the dynamics that have shaped our current treatment of women who undergo coronary artery bypass grafting (CABG) and summarize the current literature on surgical revascularization in women. There has been improved access to CABG over the past several decades. Despite this, compared with men, CABG in women involves fewer grafts and less frequent use of arterial grafts, the latter having improved long-term patency compared with saphenous vein grafts. We attempt to determine whether the adverse clinical profile of women, when referred for CABG is responsible for this finding. Female coronary anatomy and pathophysiology are reviewed and an attempt is made to understand how this might affect decisions of selection and outcome measures post CABG. We review the short-term, long-term, and quality of life outcomes in women. These data are taken from large databases, as well as from more recent publications. Randomized controlled trial data and meta-analytic data are used when available. Differential use of and outcomes of surgical strategies, including off-pump CABG and total arterial revascularization, are contrasted with those in men. This review shows that there continues to be widespread differences in surgical approach to coronary artery disease in female vs male patients. We provide evidence suggestive of the existence of issues specific to women that affect selection for surgical procedures and outcomes in women. More work is required to understand the reason for these differences and how to optimize sex-specific outcomes.