In CABG, women less likely than men to receive guideline-recommended techniques
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Among patients who underwent CABG, women were less likely than men to have procedures performed according to guideline recommendations, researchers reported at the virtual Society of Thoracic Surgeons Annual Meeting.
“Females tend to present with symptoms of coronary artery disease on average 10 years later than men, and these symptoms are more likely to be atypical,” Oliver K. Jawitz, MD, MHS, resident in the department of surgery at Duke University, said during a press conference. “Because of these atypical symptoms, females with cardiovascular disease tend to have a longer time from symptom to diagnosis. They are also less likely to receive guideline-concordant medical treatment. Female patients are less likely to be referred for invasive testing and treatment [and are] more likely to die after experiencing a heart attack or undergoing CABG surgery compared with male patients.”
Several studies have shown that women are as much as twice as likely to die after CABG than men, but they have limitations preventing researchers from understanding exactly why that is, according to Jawitz. Differences in existing comorbidities, disease severity and postoperative complications may play a role, but the investigators wanted to determine whether differences in guideline-concordant surgical practices by sex may also be responsible, he said.
The researchers analyzed concordance with three guideline recommendations: use of the left internal mammary artery (LIMA) to bypass the left anterior descending (LAD) artery; complete revascularization; and multiple arterial grafting. The population was 1,212,487 patients (25% women) from the STS Adult Cardiac Surgery Database who had a first isolated CABG from 2011 to June 2019.
Compared with men, women were older, less likely to be white, more likely to have diabetes and more likely to have a history of congestive HF, Jawitz said.
Women were less likely than men to have LIMA used in LAD revascularization (adjusted OR = 0.79; 95% CI, 0.75-0.83; P < .0001), to undergo complete revascularization (aOR = 0.86; 95% CI, 0.83-0.9; P < .0001) and to have multiple arterial grafting (aOR = 0.78; 95% CI, 0.75-0.81; P < .0001), he said during the press conference.
“In the context of the published literature, it is clear that sex disparities exist in all aspects of care for CAD, including diagnosis, referral for treatment and now in approaches to CABG,” Jawitz said during the press conference. “Standardizing revascularization techniques across sexes must be a priority to improve the clear and persistent disparity in CAD outcomes between males and females.”
“Inferior surgical results can be at least partially explained by the authors’ findings that women who undergo coronary bypass surgery are more likely to be older, smaller, nonwhite, diabetic and in congestive heart failure than their male counterparts,” Robbin G. Cohen, MD, MMM, professor of surgery at Keck Medicine of USC, said during a discussant presentation at the press conference. “What is unexplained is why we have failed to apply the same surgical strategies in women that have proved to produce better surgical results in men. My guess is the explanations are both technical and systemic. The surgical details of applying these techniques in women who have smaller vessels and more diffuse coronary artery disease may, quite frankly, take some surgeons out of their comfort zones. With improved training, enhanced experience and greater awareness, this can be overcome. The greater issue is our need to learn more about and improve all aspects of the way we approach coronary artery disease in women, from diagnosing and referring to surgery earlier to developing surgical strategies that will at the very least equal the results that we see in men.”
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Jawitz OK, et al. Adult cardiac top-scoring abstracts. Presented at: Society of Thoracic Surgeons Annual Meeting; Jan. 29-31, 2021 (virtual meeting).
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