Women with chronic severe coronary artery disease may derive greater long-term benefits from coronary artery bypass grafting (CABG) surgery compared with percutaneous coronary intervention (PCI), the findings of a study published in the European Heart Journal (EHJ) have shown.
The study adds much-needed evidence to guide decisions for women with heart disease—the leading cause of death in women worldwide—the study’s authors state. Historically, women have made up a small proportion of the population in large, prospective clinical trials comparing CABG and PCI, making it hard to draw conclusions about their outcomes.
“If you are a man, and you need coronary revascularisation, you will receive what we call evidence-based treatment, because there is strong evidence to guide your treatment decision,” said the study’s senior author Mario Gaudino (NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA). “If you are a woman, that’s not the case. We don’t have data, and so we use the data generated in men. However, we all know that women are not small men.”
In their paper, Gaudino and colleagues acknowledge that women differ from men in the development of coronary artery disease in several ways, notably that they tend to develop the disease at an older age and have, on average, smaller, more vasoreactive coronary arteries and grafts, less obstructive disease, and more microvascular disease.
Gaudino’s team partnered with University of Toronto investigators to conduct a propensity score-matched retrospective cohort analysis linking clinical and administrative databases in Ontario, Canada to identify women with chronic severe CAD undergoing PCI or CABG from 2012 to 2021. A subset of 4,066 women were matched by their characteristics to emulate a randomised clinical trial. The dataset included, on average, five years of follow-up data for each woman.
“We were very fortunate to have access to this unique dataset,” said lead author Kevin An (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, USA), who conducted this research while a research fellow in cardiothoracic surgery at Weill Cornell Medicine. “It allowed us to look at a large number of women with severe coronary artery disease in a real-world setting and follow their long-term outcomes.”
They found that about 36% of the women who underwent PCI experienced major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of all-cause mortality, myocardial infarction (MI), stroke, or repeat revascularisation. By comparison, only 22% of the women who underwent bypass surgery had such an event.
Women who underwent PCI also had about a 30% higher risk of dying from any cause during the entire follow-up period than women who underwent bypass. During the first six months after the procedures, however, death risks were similar between the two groups.
“Over the long term, bypass surgery seems to be more protective compared to stenting,” said An. There was, however, one trade-off: women who underwent stenting had a slightly lower stroke risk than women who underwent bypass surgery.
“Currently, women are about half as likely to undergo bypass surgery as men.”
“More definitive data are needed to change practice guidelines,” said Gaudino. He and his team are conducting a large prospective clinical trial comparing the two interventions in women with severe coronary artery disease to fill that evidence gap.
“For now, treatment decisions should remain individualised,” adds An. “Although our study suggests that bypass surgery may offer more long-term protection compared to stents, anatomical considerations, individual surgical risk, and patient preferences remain critical.”
