Women are significantly less likely than men to undergo coronary artery bypass grafting (CABG) using guideline-recommended approaches, potentially resulting in worse outcomes after surgery, research presented at the 57th Annual Meeting of The Society of Thoracic Surgeons (STS 2021, 29–31 January, virtual) has concluded.
The findings were presented by Oliver K Jawitz (Duke University, Durham, USA) who described the analysis of detailed demographic, clinical, and procedural data from more than 1.2 million patients, using data from the STS Adult Cardiac Surgery Database—which contains records of nearly all CABG procedures performed in the USA—to identify adult patients who underwent first-time isolated CABG from 2011 to 2019.
“This study highlights key differences between women and men in surgical techniques used for CABG and reveals opportunities to improve outcomes in women,” said Jawitz.
The correlation between female sex and three different CABG surgical techniques that are recommended in official US and European guidelines was examined closely. According to Jawitz, all of these surgical approaches—grafting of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery, complete revascularisation, and multiarterial grafting—have been associated with improved short and/or long-term outcomes. However, the results showed that women were 14%‒22% less likely than men to undergo CABG procedures with these revascularisation strategies.
“With these findings, we did in fact see less aggressive treatment strategies with women,” said Jawitz. “It is clear that sex disparities exist in all aspects of care for patients with coronary artery disease (CAD), including diagnosis, referral for treatment, and now, in surgical approaches to CABG. We must ensure that female patients undergoing CABG are receiving evidence-based, guideline-concordant techniques.”
While multifactorial, the undertreatment of CAD in women largely stems from a failure to recognise key differences in cardiovascular risk factors and symptoms in females compared with males, commented Jawitz.
Women are much more likely to experience atypical, subtler symptoms of heart disease such as fatigue, abdominal pain, nausea, vomiting, indigestion, and back pain. Sometimes, women do not even feel the obvious chest pain and pressure that are characteristic of CAD. As far as risk factors, women have their own unique set, including relatively high testosterone levels prior to menopause, increased hypertension during menopause, and higher levels of stress and depression.
“Delayed diagnosis of CAD in women leads to late initiation of key behavioural and pharmacologic interventions for minimising heart disease risk, as well as delayed referral for invasive diagnostic and therapeutic procedures, including surgical revascularization with CABG,” said Jawitz. “This often means that by the time female patients undergo these procedures, they have more severe disease than males, as well as a greater number of comorbidities, which leads to worse outcomes.”
“The evidence available for various therapies and interventions is disproportionally based on male cardiovascular biology,” said Jawitz. “But as research in this area becomes more robust, data will continue to emerge showing that cardiovascular disease manifests differently by sex. Raising awareness will go a long way toward minimising sex differences in CAD outcomes.”
Moving forward, guidelines must be developed that reflect the important differences between men and women in CAD manifestation, which certainly will require increased representation of female patients in clinical trials of cardiovascular therapies, explained Jawitz.
“Now that we have identified specific differences in surgical approaches to CABG between females and males, we must further elucidate how these differences result in disparate outcomes such as increased mortality, readmissions, and complications,” he said. “These findings will help inform the development of sex-specific guidelines for the diagnosis and management of cardiovascular disease.”