Ethnic disparities in outcomes of coronary artery bypass grafting in Israel

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Multivessel coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) (n=6330). Intervention: Arab ethnicity vs. Jewish ethnicity. Primary outcome: Major adverse cardiac and cerebrovascular events (MACCE: composite of all-cause mortality, cerebrovascular accident, myocardial infarction, and repeat revascularization) (Adjusted HR 1.073 (Crude HR 1.184), 95% CI 0.965-1.193, p=0.19).

Q: What does this research mean for the field?

After multivariable adjustment for baseline cardiovascular risk factors and socioeconomic status, ethnicity is not independently associated with worse long-term clinical outcomes or mortality following coronary artery bypass grafting in Israel. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Dror B. Leviner; Tom Ronai; Dana Abraham; Ely Erez; Guy Witberg; Yaron Yishai; Joul Hadad; Erez Sharoni

doi:10.1371/journal.pone.0356423

November 6, 2026PLoS ONEOpen Access

Ethnic disparities in outcomes of coronary artery bypass grafting in Israel

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Why the study?

Ethnic disparities after cardiac surgery are well reported, and Israeli Arabs have lower life expectancy and a greater frequency of cardiovascular risk factors, motivating a comparison of long-term outcomes following CABG between Arab and Jewish patients in Israel.

Does Arab ethnicity compared to Jewish ethnicity affect long-term major adverse cardiac and cerebrovascular events (MACCE) in adult patients undergoing isolated CABG in Israel?

Key Points

To compare long-term clinical outcomes following coronary artery bypass grafting between Arab and Jewish patients with multivessel disease in Israel.
Retrospective study of 6,330 adult patients (1,819 Arab and 4,511 Jewish) undergoing isolated coronary artery bypass grafting across three centers between January 1, 2009, and December 31, 2023.
Evaluated a primary composite outcome of major adverse cardiac and cerebrovascular events (all-cause mortality, stroke, myocardial infarction, and repeat revascularization) over a median follow-up of 78.32 months using multivariable Cox models.
Arab patients had a higher crude incidence of the primary outcome at median follow-up compared to Jewish patients (46.26% vs 40.90%, HR 1.184, 95% CI: 1.09–1.286, P < 0.001), but risk did not differ significantly after multivariable adjustment (adjusted HR 1.073, 95% CI: 0.965–1.193, P = 0.19).
Cumulative mortality rates were nearly identical between Arab and Jewish groups at median follow-up (26.44% vs 26.45%, HR 1.004, 95% CI: 0.901–1.118, P = 0.82; adjusted HR 1.055, 95% CI: 0.923–1.205, P = 0.43).
Short-term 30-day major adverse cardiac and cerebrovascular event rates did not differ between Arab and Jewish cohorts (3.96% vs 3.88%, HR 1.02, 95% CI: 0.741–1.289, P = 0.87; adjusted HR 1.118, 95% CI: 0.842–1.484, P = 0.44).

Study Design

Type

Cohort (n=6,330)

Multicenter

Yes

Structured PICO

Does Arab ethnicity compared to Jewish ethnicity affect long-term major adverse cardiac and cerebrovascular events (MACCE) in adult patients undergoing isolated CABG in Israel?

P

Population

6,330 adult Israeli patients (28.74% Arab, 71.26% Jewish) with multivessel disease undergoing isolated CABG at three cardiac surgery centers, followed for a median of 78.32 months.

E

Exposure

Arab ethnicity (exposure group undergoing isolated on-pump or off-pump CABG)

C

Comparator

Jewish ethnicity (reference group undergoing isolated on-pump or off-pump CABG at the same three centers)

O

Outcome

Composite of major adverse cardiac and cerebrovascular events (MACCE: all-cause mortality, cerebrovascular accident [CVA], myocardial infarction [MI], and repeat revascularization) at a median follow-up of 78.32 monthscomposite

Main Result

Hazard Ratio: 1.073 (95% CI 0.965–1.193)

Absolute Event Rate: 46.26% vs 40.9%

p-value: p=0.19

Unadjusted ethnic disparities in long-term cardiovascular events after CABG in Israel are driven by baseline comorbidity burden and socioeconomic status rather than surgical quality or multiarterial grafting utilization, highlighting the need for targeted postoperative secondary prevention.

Limitations

Retrospective, non-randomized cohort design
Lack of data regarding the extent of coronary artery disease before surgery (e.g., SYNTAX score, left main disease)
Lack of data regarding detailed operative strategy (e.g., conduit selection, sequential grafting, number of distal anastomoses, completeness of revascularization, target vessel quality)
Retrospective, non-randomized cohort design with inherent selection biases
Missing data on pre-operative extent of coronary artery disease (e.g., SYNTAX score, left main disease)
Missing data on operative strategy details (e.g., specific conduit selection, sequential grafting, number of distal anastomoses, completeness of revascularization, target vessel quality)

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Implication

No independent ethnic effect on post-CABG MACCE after adjustment; leaves open whether comorbidity-focused secondary prevention narrows observed disparities.

Abstract

Objective Ethnic disparities after cardiac surgery are well reported. Israeli Arabs have lower life expectancy and greater frequency of cardiovascular risk factors. We sought to compare long-term outcomes following coronary artery bypass grafting (CABG) between Arab and Jewish patients in Israel. Methods Retrospective study of adult patients with multivessel disease undergoing isolated CABG in three centers between January 1 st , 2009, and December 31 st , 2023. The primary outcome was a composite of major adverse cardiac and cerebrovascular events (MACCE). The cumulative incidence of MACCE was plotted using KM curves. The hazard ratio (HR) for Arabs vs. Jewish were calculated using multivariate Cox models. Results Our cohort included 6,330 patients, 1,819 (28.74%) and 4,511 (71.26%) patients were Arabs and Jewish, respectively. Median follow-up time was 78.32 months. Arab patients had higher rate of the primary outcome at median follow-up (46.26% vs 40.90%, HR 1.184, 95%CI: 1.09–1.286, P < 0.001) and there was no difference in mortality between the two groups (26.44% vs 26.45%, HR 1.004, 95%CI: 0.901–1.118, P = 0.82). After multivariable adjustment, the risk of MACCE was similar between the groups (adjusted HR 1.073, 95%CI: 0.965–1.193, P = 0.19). Conclusions After multivariable adjustment for baseline and socioeconomic factors, ethnicity was not independently associated with worse long-term clinical outcomes in patients undergoing CABG in Israel, while unadjusted disparities remained evident.

Discussion

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Cite This Study

Leviner et al. (2026) conducted a cohort in Multivessel coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) (n=6,330). Arab ethnicity vs. Jewish ethnicity was evaluated on Major adverse cardiac and cerebrovascular events (MACCE: composite of all-cause mortality, cerebrovascular accident, myocardial infarction, and repeat revascularization) (Adjusted HR 1.073 (Crude HR 1.184), 95% CI 0.965-1.193, p=0.19).

synapsesocial.com/papers/6aefbd4950d2071ffda4bc52 https://doi.org/10.1371/journal.pone.0356423

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Ethnic disparities in outcomes of coronary artery bypass grafting in Israel

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Ethnic disparities in outcomes of coronary artery bypass grafting in Israel

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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