The March 2023 issue of JAMA Surgery published a retrospective registry on intraoperative results of myocardial revascularization surgery (MRS) in the United States from 2011 through 2020.1 The Society of Thoracic Surgeons database was used in this registry. It includes data from 1100 hospitals, which represents over 95% of the overall volume of MRSs performed in that country.2 Overall, the authors analyzed the surgical results of 317 716 women, which represents 24.5% of all isolated myocardial surgeries (MRS only) performed during that time. Like authors say there is evidence that women have a higher procedural mortality compared to men. Also, the objective of the registry was to analyze the tendencies seen over the past decade in this group with the expectation that better results would be found in women.3 Procedural mortality was defined as all-cause mortality 30 days after MRS. The study secondary endpoint was a composite of procedural morbidity and mortality defined as procedural mortality, stroke, renal failure, reoperation, deep surgical site infection, mechanical ventilation or long length of stay.1

To conduct the primary analysis and estimate whether there was an association between feminine sex and procedural outcomes, the authors led by Mario Gaudino, head of the Department of Cardiothoracic Surgery at Weill Cornell Medical Center, United States, envisioned a clever statistical method. They basically first used data from operated men (979 488 patients) to build a multivariate logistics regression model by assessing the primary and secondary endpoints. With the results from this analysis, they created a ratio to estimate the risk of every woman treated with MRS. Afterwards, they estimated how the year (from 2011 through 2020) may have impacted the results. Therefore, ratios > 1 (by definition, 1 is the outcome for men) could be interpreted that the feminine sex was associated with an additional risk compared to men. Similarly, negative ratios could be attributed to the fact that the woman was “protected” from suffering the event. It’s interesting to see that this is how they eliminated the covariate sex as an independent predictor variable, as well as others attributed to feminine sex as body surface area or the levels of hematocrit.

When the baseline characteristics were studied prior to variable adjustment, women turned out to be older, had more hypertension, diabetes, chronic obstructive pulmonary disease, and cerebrovascular and peripheral disease compared to men. Also, they had more symptoms like non-ST-segment elevation acute coronary syndrome, and more emergency MRSs had been performed on them. On the other hand, women had higher rates of 1-vessel disease, and lower rates of 3-vessel disease of left main coronary artery disease being all the variables previously described statistically significant.

When the study primary endpoint—unadjusted—was analyzed, the authors found a higher mortality rate in women (2.8% vs 1.7%; P < .001), and also a higher rate of the composite endpoint (22.9% vs 16.7, P < .001). These were the results of the ratio-based analysis: somewhere between 1.28 in 2011 and 1.41 in 2020 without significant changes being reported across the period studied; similar results were seen regarding morbidity and mortality (1.08 in 2011 and 2020) without any significant changes being reported in the years studied.

Based on former studies, the authors interpreted that women have a higher procedural mortality and morbidity compared to men.3,4 Although there is evidence that MRS has improved its results over the past 2 decades, these results do not seem to have been found among women.5

Percutaneous coronary intervention (PCI) shows similar results, although no head-to-head randomized clinical trials have ever been conducted comparing PCI and MRS in female patients.6,7 This study shows that, currently, it is still unclear as to what the best revascularization treatment is for women. This has been misrepresented in numerous randomized clinical trials conducted on which current evidence, and treatment guidelines are based on. Time has come to reevaluate the strategies regarding women and fill the enormous empty gap of figuring out how they should be revascularized.

Alfredo E. Rodríguez MD,PhD,FACC
Editor-in-chief
Revista Argentina de Cardioangiologia Intervencionista (RACI)

1. Gaudino M, Chadow D, Rahouma M, et al. Operative Outcomes of Women Undergoing Coronary Artery Bypass Surgery in the US, 2011 to 2020. JAMA Surg. 2023 Mar 1:e228156. doi: 10.1001/jamasurg.2022.8156. Epub ahead of print.

2. Jacobs JP, Shahian DM, Grau-Sepulveda M, et al. Current penetration, completeness, andrepresentativeness of The Society of ThoracicSurgeons Adult Cardiac surgery database. Ann Thorac Surg 2022;113(5):1461-8. doi:10.1016/j.athoracsur.2021.04.107.

3. Bryce Robinson N, Naik A, Rahouma M, et al. Sex differences in outcomes following coronary artery bypass grafting: a meta-analysis. Interact Cardiovasc Thorac Surg 2021;33(6):841-7. doi:10.1093/icvts/ivab191.

4. Gaudino M, Di Franco A, Alexander JH, et al. Sex differences in outcomes after coronary artery bypass grafting: a pooled analysis of individual patient data. Eur Heart J 2021;43(1):18-28. doi:10.1093/eurheartj/ehab504.

5. Alkhouli M, Alqahtani F, Kalra A, et al. Trends incharacteristics and outcomes of patients undergoing coronary revascularization in theUnited States, 2003-2016. JAMA Netw Open 2020;3(2):e1921326. doi:10.1001/jamanetworkopen.2019.21326.

6. Kosmidou I, Leon MB, Zhang Y, et al. Long-term outcomes in women and men following percutaneous coronary intervention. J Am Coll Cardiol 2020;75(14):1631-40. doi:10.1016/j.jacc.2020.01.056.

7. Gul B, Shah T, Head SJ, et al. Revascularization options for females with multivessel coronary artery disease: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv 2020;13(8):1009-10. doi:10.1016/j.jcin.2019.12.036.

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The importance of gender differences when choosing the revascularization strategy

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