Improving outcomes for women after coronary artery bypass grafting: A case for prevention

Editorial Note: The gender initiative, a provocative series addressing gender differences in the surgical treatment of cardiac, vascular, and thoracic disease, continues with editorials addressing long-term outcomes of coronary artery surgery in women. Suzanne Oparil, MD, a cardiologist renowned for clinical and laboratory studies of women with cardiovascular disease, provides an excellent overview. Viola Vaccarino, MD, PhD, and Colleen Koch, MD, address specific issues involving cardiac rehabilitation, quality of life, relief of symptoms, and long-term survival after cardiac surgery. The series continues next month with editorials addressing valvular heart disease in women. Nancy A. Nussmeier, MD Texas Heart Institute See related articles on pages 1707, 2032, and 2044. I n this issue of the Journal,Vaccarino and Koch and Koch and associates come to grips with the knotty and contentious problem of why women have poorer outcomes than men after coronary artery bypass grafting (CABG). They use a database of 15,597 patients, including 3596 women, who underwent isolated CABG surgery at a single institution between 1993 and 2002 to address the question: “Is female gender a marker or a cause of increased risk of poor outcomes after coronary revascularization?” They observe an increased burden of cardiovascular disease risk factors and comorbid conditions, including hypertension, insulin-treated diabetes, heart failure, renal disease, peripheral vascular disease, and elevated low-density lipoprotein cholesterol and triglyceride levels, in women compared with men. Further, women had a more unstable presentation, including a higher prevalence of unstable angina, preoperative intraaortic balloon pump usage, and emergency surgery, compared with men. When propensity modeling techniques were used, only 26% of women could be matched on propensity scores with men because of the greater prevalence of risk factors and comorbidities among the women. While unadjusted postoperative morbidity and mortality outcomes were worse for women than for men overall, in well-matched patients, female gender was not a risk factor for in-hospital mortality and had minimal impact on postoperative morbidity. The authors go on to discuss gender disparities in the long-term outcomes of CABG surgery, which include less relief of angina, more dyspnea, and lower functional status in women, without a reduction in survival. They point out an encouraging trend toward improved CABG outcomes in women, which they relate to technical advancements in surgical and myocardial protection techniques. The cardiovascular surgeons and their colleagues in anesthesiology deserve kudos for the major advances that they have made in this area. To achieve further gains in CABG outcomes for women, however, it is apparent that more needs to be done to facilitate the earlier diagnosis of clinically important coronary artery disease and related comorbid conditions in women. This approach should improve their cardiovascular risk profiles at the time of presentation for surgery, as well as their perioperative and postoperative outcomes. Even more important, aggressive strategies of lifestyle modification and cardiovascular risk factor reduction are urgently needed to reduce both the risk of CABG surgery and the need for the procedure in older women. Effective methods for reducing cardiovascular risk by both lifestyle modification and pharmacologic means are clearly available, but there is evidence that these are underused in the very women who are at highest risk for cardiovascular disease and therefore become candidates for CABG surgery. For example, hypertension, the most common modifiable cardiovascular risk factor in women, is clearly inadequately managed in older women. The majority of women over age 65 years in the United States are hypertensive, and the prevalence of hypertension tracks closely with the prevalence of cardiovascular disease. Abundant clinical trial evidence indicates that antihypertensive therapy is highly effective in preventing target organ damage, including heart attack, heart failure, and stroke, in women, as well as in men. Nevertheless, as shown in data from the Women’s Health Initiative (WHI), hypertension is undertreated and inadequately controlled in women, particularly in high-risk elderly women. In the WHI cohort, blood pressure control rates were From the Division of Cardiovacular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Ala.