Multiple arterial grafting in CABG may confer poorer outcomes in women vs. men
Click Here to Manage Email Alerts
Multiple arterial grafts during CABG were associated with better mortality vs. single multiple arterial grafting, but women experienced worse mortality and risk for major adverse events compared with men, researchers reported.
“This paper does not imply that multiple arterial grafting should not be used in women. This is not what we are saying. When we stratified women by survival probability or mortality risk, the majority of woman did, in fact, benefit from the use of multiple arterial grafting,” Mario F.L. Gaudino, MD, FEBCTS, Stephen and Suzanne Weiss Professor of Cardiothoracic Surgery at Weill Cornell Medicine, told Healio. “However, when you look at the overall group of women, you do not see the treatment effect anymore. This is because the number of women at high risk is much higher than in men. In men, the effect of multiple arterial grafting is seen both in the subgroup and the general population. In women, this is not the case, and in the overall proportion of women, the benefit from multiple arterial grafting is small.”
For this statewide cohort study, published in JAMA Cardiology, researchers utilized data from New York’s Cardiac Surgery Reporting System and Vital Statistics file to identify 63,402 patients (76% men; mean age, 70 years) who underwent single or multiple arterial grafts during CABG from 2005 to 2014.
Researchers assessed the incidence of mortality, acute MI, stroke, repeat revascularization, major adverse cardiac and cerebrovascular events (composite of mortality, acute MI and stroke) and major adverse cardiac events (composite of mortality, acute MI or repeat revascularization) among 9,512 propensity-matched men and 1,860 propensity-matched women.
Overall, women had worse baseline characteristics compared with men, including older mean age and greater prevalence of diabetes.
At 7 years, for men, mortality was lower in those who had multiple arterial grafting than in those who had single arterial grafting (adjusted HR = 0.8; 95% CI, 0.73-0.87), but the same was not true for women (aHR = 0.99; 95% CI, 0.84-1.15), according to the researchers.
In both sexes, multiple arterial grafting conferred lower risk for mortality and major adverse CV events compared with single arterial grafting in low-risk patients but not in high-risk ones, Gaudino and colleagues found.
Tailored revascularization strategies needed
“The revascularization strategy needed to be tailored and individualized to the patient,” Gaudino told Healio. “The difference in patency rate between artery and vein become statistically significant after 4 or 5 years of follow-up. Patients who do not have long life expectancies just do not live long enough to see the benefit of multiple arterial grafting.
“The other important message is that the treatment effect in women is different than in men, but everything related to CABG in women is different than in men: the operative results, the long-term results, the effect of multiple arterial grafting, etc,” Gaudino said in an interview. “This is a reminder that we need to look at women as a separate group; we needed to include more women in randomized trials; ideally, we should design randomized trials that focus only on women, and stop thinking that what we see in the general population, which is mostly men, also applies to women.”
After full adjustment, multiple arterial grafting was inversely associated with mortality (aHR = 0.53; 95% CI, 0.46-0.61); however, female sex (aHR = 1.44; 95% CI, 1.26-1.64; P < .001) and risk score (aHR = 1.28; 95% CI, 1.27-1.29; P < .001) were both positively associated with mortality.
Future research
“I am currently exploring the possibility of a randomized trial on this topic that will focus only on women. I am the principal investigator of ROMA, the largest CABG trial that tested the multiple arterial grafting hypothesis,” Gaudino told Healio. “We are exploring the option to leverage ROMA to then perform a separate trial that will enroll only women.
“We strongly believe that we cannot assume that what we see in the general population is true also in women,” Gaudino said. “There are sex-related differences that are really important, and it is crucial that as a community, cardiothoracic surgeons start using a different approach to improve outcomes of both women and men after CABG.”
For more information:
Mario F.L. Gaudino, MD, FEBCTS, can be reached at mfg9004@med.cornell.edu.
Collapse
Read more about
Click Here to Manage Email Alerts