Sex differences in outcomes after coronary artery bypass grafting: a pooled analysis of individual patient data
Why the study?
Data suggesting worse outcomes for women than men after CABG have been inconsistent, potentially due to suboptimal risk adjustment in low-quality data.
Does female sex increase the risk of adverse cardiovascular outcomes compared to male sex in patients undergoing coronary artery bypass grafting?
Structured PICO
Does female sex increase the risk of adverse cardiovascular outcomes compared to male sex in patients undergoing coronary artery bypass grafting?
P
Population
13,193 patients (10,479 males; 2,714 females) from 4 large coronary artery bypass grafting (CABG) trials
I
Intervention
Female sex (undergoing coronary artery bypass grafting)
C
Comparator
Male sex (undergoing coronary artery bypass grafting)
O
Outcome
Composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE) over 5 yearscomposite
This pooled analysis of individual patient data demonstrates that women experience worse composite cardiovascular outcomes than men in the first 5 years after CABG, driven by MI and repeat revascularization, though mortality is similar.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This should be a 'wake-up call' for cardiothoracic surgeons—women still have a higher risk of adverse outcomes following coronary artery bypass surgery, and there doesn't seem to have been any change in this trend over the past decade.”
“The study by Gaudino et al. should be regarded as an exploding flare in the sky for all clinicians who care for women.”
SSSigrid SandnerCardiac surgeon, Medical University of Vienna
“When we talk about disparities in outcomes of CABG between women and men, what we need to recognise is that in the treatment of coronary disease in women there is a disparity along every step of the way—from preoperative to postoperative—that contributes to these differences in outcomes that we are seeing.”
Implication
May warrant sex-specific post-CABG prevention; extends high-level RCT evidence of persistent outcome disparities.**[[1]](https://pubmed.ncbi.nlm.nih.
Abstract
AIMS: Data suggest that women have worse outcomes than men after coronary artery bypass grafting (CABG), but results have been inconsistent across studies. Due to the large differences in baseline characteristics between sexes, suboptimal risk adjustment due to low-quality data may be the reason for the observed differences. To overcome this limitation, we undertook a systematic review and pooled analysis of high-quality individual patient data from large CABG trials to compare the adjusted outcomes of women and men. METHODS AND RESULTS: The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE). The secondary outcome was all-cause mortality. Multivariable mixed-effect Cox regression was used. Four trials involving 13 193 patients (10 479 males; 2714 females) were included. Over 5 years of follow-up, women had a significantly higher risk of MACCE [adjusted hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.21; P = 0.004] but similar mortality (adjusted HR 1.03, 95% CI 0.94-1.14; P = 0.51) compared to men. Women had higher incidence of MI (adjusted HR 1.30, 95% CI 1.11-1.52) and repeat revascularization (adjusted HR 1.22, 95% CI 1.04-1.43) but not stroke (adjusted HR 1.17, 95% CI 0.90-1.52). The difference in MACCE between sexes was not significant in patients 75 years and older. The use of off-pump surgery and multiple arterial grafting did not modify the difference between sexes. CONCLUSIONS: Women have worse outcomes than men in the first 5 years after CABG. This difference is not significant in patients aged over 75 years and is not affected by the surgical technique.
Discussion
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Cite This Study
Gaudino et al. (2021) studied this question.