Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women

Female gender and the risk for death after cardiac surgery in septuagenarians and octogenarians: a retrospective observational study

BACKGROUND

In elderly patients, the impact of gender on outcome after cardiac surgery is a debated topic of ongoing relevance.

OBJECTIVE

This study assessed the hypothesis that, among septuagenarians and octogenarians, women have poorer outcomes compared with men after cardiac surgery.

METHODS

For this retrospective observational study, the electronic medical records of patients who underwent cardiac surgery between January 2006 and August 2009 at Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany, were reviewed. The primary end points were the proportions of women and men with in-hospital and 30-day mortality, and postoperative morbidity was considered a secondary end point.

RESULTS

The records of 598 patients were reviewed (274 female [137 septuagenarians, 162 octogenarians; mean (SD)] age, 77.8 [4.8] years]; 324 male [137 septuagenarians, 162 octogenarians; mean age, 78.3 [4.8] years]; all, P = NS). At baseline, the gender groups differed significantly with respect to mean logistic European System for Cardiac Operative Risk Evaluation score (EuroSCORE) (used for calculating expected mortality) (11.9% in women, 9.9% in men; P = 0.007), rate of diabetes mellitus did not reach statistical significance ([statistical significance was considered at P < 0.05] 12.4% vs 7.4%; P = 0.052), rate of renal dysfunction (51.5% vs 28.6%; P < 0.001), proportion undergoing isolated valve surgery (43.1% vs 24.7%, respectively; P < 0.0001), and perfusion technique (conventional [83.2% vs 69.4%] vs minimized [16.8% vs 30.6%] extracorporeal circulation) (P < 0.0001). In-hospital mortality (7.3% vs 5.6%; P = 0.404) and 30-day mortality (8.0% vs 5.9%; P = 0.332) were not significantly different between genders. There were no significant differences in mortality with respect to age group. On multivariate analysis, age and female gender were not found to be independent risk factors for early mortality. The between-gender differences in postoperative morbidity, including central neurologic event (P = 0.412), need for dialysis (P = 0.491), and respiratory insufficiency (P = 1.00), were nonsignificant, as were median durations of intensive care unit stay (P = 0.68) and hospital stay (P = 0.52) stay.

CONCLUSION

In septuagenarians and octogenarians, female gender was not associated with increased risks for morbidity and mortality after cardiac surgery.

Sex, clinical symptoms, and angiographic findings in patients with diabetes mellitus and coronary artery disease (from the Bypass Angioplasty Revascularization Investigation [BARI] 2 Diabetes trial)

Previous studies have reported differences in presenting symptoms and angiographic characteristics between women and men undergoing evaluation for suspected coronary artery disease (CAD). We examined the relation between symptoms and extent of CAD in patients with type 2 diabetes mellitus and known CAD enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Of 1,775 patients (533 women, 30%, and 1,242 men, 70%), women were more likely than men to have angina (65% vs 56%, p <0.001) or an atypical angina/anginal equivalent (71% vs 58%, p <0.001). More women reported unstable angina (17% vs 13%, p = 0.047) or were in a higher Canadian Cardiology Society class compared to men (Canadian Cardiology Society classes II to IV 78% vs 68%, p = 0.002). Fewer women than men had no symptoms (14% vs 22%, p <0.001). Women had a lower mean myocardial jeopardy index (42.5 ± 24.3 vs 47.9 ± 24.3, p <0.001), smaller number of total significant lesions (2.3 ± 1.7 vs 2.7 ± 1.8, p <0.001), and fewer jeopardized left ventricular regions (p <0.001 for distribution) or long-term occlusions (29% vs 42%, p <0.001). After adjustment for relevant covariates, the odds of having CAD symptoms were still higher in women than men (odds ratio for angina 1.31, 95% confidence interval 1.02 to 1.69; odds ratio for atypical angina 1.52, 95% confidence interval 1.17 to 1.96). In conclusion, in a high-risk group of patients with known CAD and diabetes mellitus, women were more symptomatic than men but had less obstructive CAD. These data suggest that factors other than epicardial CAD severity influence symptom presentation in women in this population.

Gender differences in clinical presentation and management of patients with acute coronary syndrome in Southwest of Saudi Arabia

OBJECTIVE

Gender differences in the clinical presentation and management of patients with acute coronary syndrome (ACS) have been reported in different parts of the world with contradicting results. We aimed at investigating the presence of gender bias in patients admitted with ACS to Aseer Central Hospital (ACH).

METHODS

A retrospective cohort of all consecutive patients admitted to ACH with the diagnosis of ACS, during the period between the 1st of June 2007 and the 31st of May 2009 was studied. Data on demographic and clinical profiles, management and outcomes of ACS patients were collected and compared for both genders.

RESULTS

The present study included 148 females and 397 males. Females were significantly older than males (62.9 ± 14.2 vs. 60 ± 13.4, respectively, P < 0.03), were less likely ever to have smoked (0.7% vs. 26.2%, respectively, P < 0.001), less likely to have had a history of hyperlipidemia (10.8% vs. 22.2%, respectively, P < 0.003) or family history of ischemic heart disease (10.1% vs. 18.9%, respectively, P < 0.014). Female patients presented more with atypical presentation (42.6% vs. 28.9%, respectively, P < 0.003), more with unstable angina (72.3% vs. 50.4%, respectively, P < 0.001), and less with ST-elevation myocardial infarction (18.9% vs. 40.8%, respectively, P < 0.001). Furthermore, they had significantly lower levels of hemoglobin compared to males (12.9 ± 2.3 vs. 14.5 ± 2.2 g/L, respectively, P < 0.001), and higher levels of high density lipoprotein (1.1 ± 0.4 vs. 0.98 ± 0.4 mmol/L, respectively, P < 0.008). Left ventricular ejection fraction was significantly higher in female patients compared to males (50.9 ± 14 vs. 45.8 ± 14, respectively, P < 0.003). Coronary angiography showed a higher rate of normal findings (29.3% vs. 8.9%, respectively, P < 0.001) and less severe disease (46.7% vs. 60.3%, respectively, P < 0.027) in women, however, they were less likely to undergo invasive revascularization procedures (31% vs. 42.8%, respectively, P < 0.013). No significant differences were found between both sexes regarding in-hospital mortality or re-infarction rates.

CONCLUSION

We documented gender differences in both clinical presentation as well as management of patients admitted with ACS to ACH. However, there were no significant differences between both genders regarding the clinical in-hospital outcomes. Emphasis should be made to avoid such bias in the future.

Significant association of female gender with lower degree of pathological 99mTc-sestamibi scintigraphy results as well as higher cardiac-related deaths free survival in elderly patients

BACKGROUND

The aim of the present study was to assess the impact of female gender on the extent of myocardial perfusion defects as revealed by (99m)Tc-sestamibi myocardial perfusion scintigraphy (MPS) and on emerging cardiac events (CE) in patients aged ≥ 70 years.

PATIENTS AND METHODS

86 patients aged ≥ 70 years with known or suspected CAD undergoing MPS (74.4 ± 3.2 years; women: n = 46; 53.5%) were included in this study. Semiquantitative analysis of MPS was performed and summed stress (SSS), summed difference (SDS), and summed rest scores (SRS) were calculated. Emerging CE comprised myocardial revascularization and -infarction and cardiac-related death. Multivariate regression analysis was performed to assess the independent prognostic impact of several patient related variables on MPS results. Kaplan-Meier- and log rank analyses were calculated for assessment of CE free survival as related to gender.

RESULTS

Normal SSS (87.0% vs. 27.5%; p < 0.0001), SDS (80.4% vs. 27.5%; p < 0.0001), and SRS (97.8% vs. 82.5%; p = 0.023) were significantly more often found in women, whereas incidence of mildly and severely impaired SSS (6.5% vs. 35%; p = 0.001 and 2.2% vs. 25%; p = 0.002, respectively) and SDS (15.2% vs. 52.5%; p < 0.0001 and 2.2% vs. 17.5%; p = 0.023, respectively) were significantly higher in men. Multivariate logistic regression analysis revealed female gender as an independent predictor of normal SSS (odds ratio/OR: 17.6) and SDS (OR: 53.3). Female gender was associated with a significant higher cardiac-death free survival compared to male patients (p = 0.031).

CONCLUSION

Female gender is independently associated with a significantly lower degree of pathological MPS results and a higher cardiac-death free survival in elderly patients.

Operative and early results of coronary artery bypass grafting in female patients in different body mass indexes

BACKGROUND

Female gender has been reported to be an independent risk factor for coronary artery bypass grafting (CABG) in European System for Cardiac Risk Evaluation. The effect of the body size on the CABG outcome is less clear. There is ongoing debate about obesity as a risk factor for adverse outcomes after cardiovascular procedures. The goal of this retrospective study is to evaluate the in hospital and early postoperative outcomes in severe obese, obese and normal-slightly obese female patients after CABG.

METHODS

In a four year period a total of 427 female patients underwent isolated CABG under cardiopulmonary bypass. The patients were allocated into three groups according to the Body Mass Index (BMI) as follows; group 1: severe obese patients; BMI > 35, group 2: obese patients; 30≤BMI≤35, group 3: normal-slightly obese patients; BMI < 30.

RESULTS

The patients in group 3 were older than the group1 and group 2 (65,6 ± 8,3 year vs 63,01 ± 8,0 and 63,57 ± 8,4 year p < 0,05). In group 1 diabetic patients were more than in group 2 and group 3 respectively (54,4% vs 43,4% and 40%, p < 0,05). Urgent operation was more in group 1 than in group 2 and 3 respectively (37,6% vs 17,2% and 21,2% p < 0,05). The patients in group 3 had significantly greater postoperative drainage at 24 h compared with values in group 1 and group 2 (647 ± 142 ml vs. 539 ± 169 ml and 582 ± 133 ml, p < 0,05). Mortality rate in group 1 was 0,8%, 0% in group 2 and 1,2% in group 3 respectively. Wound problem has occurred in 41 patients (9,6%).The percentage of postoperative wound problems was higher in group 1 but did not show statiscially difference. Following discharge a total of 43 (10,1%) patients re-hospitalized within 30 days. Re-hospitalization rate was 16,1% in group1, 9,8% in group 2 and 6,5% in group 3 (p < 0,05).

CONCLUSION

This study may give an aspect for evaluations of the inhospital-early mortality and morbidity after CABG in female patients in different BMI. Severe obesity is not a risk factor in-hospital mortality in female patients. However, severe obese female patients appear to have more wound problems and re-hospitalization rate after CABG compared to obese and normal-slightly obese patients.

Referrals in acute coronary events for CARdiac catheterization: The RACE CAR trial

BACKGROUND

Women with acute coronary syndromes have lower rates of cardiac catheterization (CC) than men.

OBJECTIVE

To determine whether sex⁄gender, age, risk level and patient preference influence physician decision making to refer patients for CC.

METHODS

Twelve clinical scenarios controlling for sex⁄gender, age (55 or 75 years of age), Thrombolysis in Myocardial Infarction risk score (low, moderate or high) and patient preference for CC (agreeable or refused⁄no preference expressed) were designed. Scenarios were administered to specialists across Canada using a web-based computerized survey instrument. Questions were standardized using a five-point Likert scale ranging from 1 (very unlikely to benefit from CC) to 5 (very likely to benefit from CC). Outcomes were assessed using a two-tailed mixed linear regression model.

RESULTS

Of 237 scenarios, physicians rated men as more likely to benefit from CC than women (mean [± SE] 4.44±0.07 versus 4.25±0.07, P=0.03), adjusted for age, risk and patient preference. Low-risk men were perceived to benefit more than low-risk women (4.20±0.13 versus 3.54±0.14, P<0.01), and low-risk younger patients were perceived to benefit more than low-risk older patients (4.52±0.17 versus 3.22±0.16, P<0.01). Regardless of risk, patients who agreed to CC were perceived as more likely to benefit from CC than patients who were disagreeable or made no comment at all (5.0±0.23, 3.67±0.21, 2.95±0.14, respectively, P<0.01).

CONCLUSION

Canadian specialists' decisions to refer patients for CC appear to be influenced by sex⁄gender, age and patient preference in clinical scenarios in which cardiac risk is held constant. Future investigation of possible age and sex⁄gender biases as proxies for risk is warranted.

Early and mid term mortality after coronary artery bypass grafting in women depends on the surgical protocol: retrospective analysis of 3441 on- and off-pump coronary artery bypass grafting procedures

Background

Since 2002 MI and stroke, not cancer, are leading causes of death in women. We studied 30-days and 1 year mortality of 3441 patients undergoing coronary artery bypass grafting (CABG) operations in our institution performed either conventionally or off pump (OPCAB). Our objective was to investigate the gender-related mortality in both groups.

Patients and Methods

Between 2004 and 2008, 3441 patients (733 women, 2708 men) underwent CABG. 252 women and 854 men were operated using OPCAB, 481 women and 1854 men using extracorporeal circulation (ECC). Medical data was prospectively entered and retrospectively reviewed. 30-days and one year mortality rates were analyzed with Kaplan-Meier estimates and Cox proportional hazards models. Linear and logistic regression models were used to test gender differences.

Results

a) 30-day mortality using ECC: 5.2% in women vs. 2.5% in men (p = 0.001). One year ECC mortality: 8.7% in women vs. 4.8% in men (p = 0.0008). b) OPCAB: 30-days and 1 year mortality in women measured 1.7%. Mortality in men was 2.1% after 30 days and 3.7% after one year c) gender specific mortality: 30 days mortality in women was 1.7% using OPCAB and 5.2% using ECC (p = 0.002), one year mortality in women was 1.7% using OPCAB vs. 8.7% using ECC (p = 0.0004). In men, 30-days mortality in OPCAB was 2.1%, one year mortality was 3.7%; using ECC early and late mortality was 2.5% and 4.8%.

Conclusions

Female gender is a strong independent predictor and risk factor of increased early and midterm postoperative mortality rates when ECC is used. OPCAB significantly reduces early and midterm postoperative mortality in women and may therefore be proposed as the preferred revascularization technique in female patients.

Effect of an invasive strategy on in-hospital outcome and one-year mortality in women with non-ST-elevation myocardial infarction

BACKGROUND

Subgroup analyses from randomized studies show inconsistent results regarding an early invasive approach in women with non-ST-elevation myocardial infarction (NSTEMI). We sought to investigate the impact of an invasive strategy in clinical practice, analyzing data from the German Acute Coronary Syndromes registry (ACOS).

METHODS

Overall 1986 consecutive women were enrolled in the registry between June 2000 and November 2002 and were divided into two groups: 1215 (61.2%) underwent coronary angiography, 771 (38.8%) received conservative treatment. In the invasive group percutaneous coronary intervention was performed in 40.7% within 48 h and in 16.4% after 48 h, whereas 8.3% underwent coronary artery bypass grafting within hospital stay.

RESULTS

In-hospital death (3.2% vs 10.5%, p<0.0001), in-hospital death/myocardial infarction (MI) (7.1% vs 14.9%, p<0.0001) and one-year death (8.1% vs 24%) occurred significantly less often in patients with invasive strategy. After adjustment of the confounding factors in the propensity score analysis the invasive strategy showed no significant benefit for in-hospital death (OR 0.86, 95% CI 0.51-1.44) or death/MI (OR 0.70, 95% CI 0.47-1.04) but remained superior for mortality (OR 0.47, 95% CI 0.3-0.7) and death/MI one year after discharge (OR 0.47, 95% CI 0.33-0.68).

CONCLUSIONS

In clinical practice women presenting with NSTEMI have a long-term benefit from an invasive therapeutic strategy with a significant reduction in mortality as well as the composite endpoint of death/MI.

Novel aspects of pharmacological therapies for acute renal failure

Acute renal failure (ARF) comprises several syndromes that are associated with a sudden decrease in renal function. ARF is common among critically ill patients, is typically multifactorial and is of great prognostic significance. Indeed, even moderate changes in renal function significantly add to the morbidity and worsen mortality associated with ARF. Recent definitions, namely the renal Risk, Injury, Failure, Loss of renal function and End-stage kidney disease (RIFLE) classification or Acute Kidney Injury Network (AKIN) criteria, which incorporate the levels of oliguria in addition to fractional serum creatinine elevation, are important because the magnitude of kidney injury according to those definitions correlates very well with both short- and long-term patient survival. However, preventive strategies are most effective when started before oliguria or elevated serum creatinine is detectable, as those criteria already reflect established renal tubular cell injury. New biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty acid binding protein (L-FABP) or kidney injury molecule-1 (KIM-1) that increase prior to the serum creatinine elevation are promising and have been proven to be useful in this regard in a few clinical trials. In addition, genetic profiling may define patients at risk earlier and help to individualize preventive strategies. Well established strategies include limiting dehydration and hypotension by the use of intravenous isotonic fluids at an optimal and individualized rate, as well as avoiding exposure to nephrotoxins, which include aminoglycosides, amphotericin or non-ionic contrast. Generally accepted and evidence-based pharmacological preventive or therapeutic options have not yet been established, although many drugs (e.g. renal vasodilators, diuretics and HMG-CoA reductase inhibitors [statins]) have been tested. New promising agents interfere with the apoptotic signalling that can occur in the setting of toxin exposure or ischaemia-reperfusion injury, limit inflammatory responses or modulate endothelial cell activation. In the future, these new approaches will enable us to extend our therapeutic repertoire.

Role of gender and age on early mortality after coronary artery bypass graft in different hospitals: data from a national administrative database

The aim of this study is to evaluate the effect of gender and age on outcome following coronary surgery in several hospitals enrolled in a national quality assessment program. Patients undergoing isolated coronary artery bypass graft (CABG) during 2003-2005 in Italy were included in the study (n=74,577). The outcome measure was 30-day in-hospital mortality. Comorbidities recorded during previous and current hospitalizations were used to define patients' health status and to build the adjustment model. The interaction term (gender*hospital) was introduced into the model to test the effect modification of gender; if present, gender specific models were analyzed to test the effect modification of age. A significant effect modification by gender was found in 39 hospitals; the adjusted odds ratios (AdjORs) showed significant increased risk for females (AdjORs ranging from 3.7 to 21.6). In three of these hospitals a significant increased risk was found for older age (AdjORs for elderly patients ranging from 8.1 to 14.6). Two hospitals showed a significant excess risk for patients ≥75 years (AdjORs=6.6 and 13.8). The technical aspects of surgery could account for the excess risk found in female patients; differences in the entire care process (intraoperative and postoperative management) could explain the variations in outcome among elderly patients.

Gender-specific characteristics of individuals with depressive symptoms and coronary heart disease

OBJECTIVE

In individuals with depressive symptoms and coronary heart disease (CHD), little is known about gender-specific characteristics that may inform treatments and outcomes. This study sought to identify characteristics that distinguish men from women with both conditions.

METHODS

By cross-sectional design, 1951 adults with CHD and elevated depressive symptoms completed questionnaires to measure anxiety, hostility, perceived control, and knowledge, attitudes, and beliefs about CHD. Gender differences were evaluated by multivariable logistic regression.

RESULTS

Women were more likely to be single (odds ratio [OR] 3.61, P < .001), to be unemployed (OR 2.52, P < .001), to be poorly educated (OR 2.52, P < .001), to be anxious (OR 1.14, P < .01), and to perceive lower control over health (OR 1.34, P < .01) than men.

CONCLUSION

Women with CHD and depressive symptoms have fewer resources, greater anxiety, and lower perceived control than men. In women, targeting modifiable factors, such as anxiety and perceived control, is warranted.

Perceptions of recovery, physical health, personal meaning, role function, and social support after first-time coronary artery bypass graft surgery

Coronary artery bypass graft surgery is one of the most frequently performed major surgeries in the United States. Because of fast-track protocols and decreased lengths of stay, critical care nurses have even more demanding challenges in the care of these patients. Critical care nurses are well aware that these patients still have health needs that extend beyond discharge from the hospital, but these needs are now addressed by the patient's caregiver. This descriptive, comparative study was conducted to examine perceptions of recovery by these patients and the relationships among physical health, personal meaning, role function, and social support. The results of the study are presented, as well as the implications for critical care nurses.

Operative mortality in women and men undergoing coronary artery bypass grafting (from the California Coronary Artery Bypass Grafting Outcomes Reporting Program)

The comparative operative mortality (OM) in women and men undergoing isolated coronary artery bypass graft surgery (CABG) has not been clarified. Therefore, we evaluated factors related to OM in a large cohort of women and men undergoing isolated CABG. Results from 121 hospitals on patients undergoing isolated CABG in 2003 and 2004 were analyzed according to gender, including demographics, clinical characteristics, and surgical outcome. A total of 10,708 women and 29,669 men had isolated CABG in 2003 to 2004. Observed mortality in women was significantly higher than in men (4.60% vs 2.53%, p <0.0001). Although men had a higher prevalence of >3 diseased coronary arteries and left ventricular dysfunction, women were more likely to be older, diabetic, have stage 3 to 5 chronic kidney disease, chronic lung disease, and nonelective CABG. Women were less likely to receive an internal mammary artery graft. Multivariate analysis indicated that women were at higher risk for OM than men (odds ratio 1.61, 95% confidence interval 1.40 to 1.84). In conclusion, data from the large state-mandated CCORP indicate that women are at increased risk of OM after isolated CABG compared to men, despite adjustment for preoperative risk factors.

Coronary heart disease in women: a challenge for the 21st century

Heart disease is the first killer of women in the modern era, regardless of age, race and of ethnicity, although its prevalence rises after menopause. Modern women have professional and housewife responsibilities, consume excess of fat and carbohydrates, smoke, do not exercise regularly and do not have enough time to rest. This situation leads to overweight, dyslipidemia, arterial hypertension, impaired glucose tolerance and diabetes. Women do not often participate in preventive studies and still undergo less intensive and invasive evaluation and treatment for chest pain when compared to men. However, the rate of coronary death is twice higher in women than in men after myocardial infarction and revascularization procedures. The objective of this review is to analyze the main gender differences regarding symptoms, diagnosis, management and prognosis of coronary heart disease and to discuss the influence of hormonal replacement therapy in the prevention of cardiovascular disease in postmenopausal women.

Solutions for disparities for women with heart disease

Cardiovascular disease (CVD) mortality and morbidity is a major burden on the US and global population. Observed differences in prevalence, incidence, outcomes, and risk factors suggest a possible sex difference in etiology and pathophysiology of CVD. Disparate rates of referral and diagnosis may be attributable to differences in symptoms, presentation, and diagnostic accuracy. Many common procedural, pharmaceutical, and medical device therapies have been associated with worse outcomes in women compared to men. Awareness campaigns and efforts to improve female inclusion in clinical trials are contributing to improvements in CVD healthcare delivery for women, but much remains unknown about the biological basis for the differences described above, such as the role of estrogen, life-cycle changes (puberty, menstrual cycle, pregnancy, menopause), and possible chromosomal or genetic mechanisms. This is where translational research is uniquely poised to make immense contributions to resolving disparities in the quality of care and outcomes for women with CVD.

Impact of sex on 3-year outcome after percutaneous coronary intervention using bare-metal and drug-eluting stents in previously untreated coronary artery disease: insights from the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) Registries

OBJECTIVES

We investigated the impact of sex on outcomes after percutaneous coronary intervention (PCI) with drug-eluting stent (DES).

BACKGROUND

Women have a higher risk of adverse outcomes after PCI than do men. However, long-term outcomes of women after contemporary PCI with DES have not been fully investigated.

METHODS

We performed a retrospective cohort study of 4,936 consecutive patients (28.2% women) who underwent PCIs between 2000 and 2004, before and after introduction of DES (bare-metal stent [BMS] group: n = 2,131, DES group: n = 2,805), to assess the impact of sex on long-term PCI outcomes and to compare outcome after PCI of women between the DES and BMS eras.

RESULTS

Compared with men, women undergoing PCIs were 5 years older and more frequently have comorbidities such as diabetes mellitus and hypertension. In patients treated throughout the BMS and DES eras, there were no differences by sex for risk of all-cause death, myocardial infarction, or target vessel revascularization 3 years after procedure. The procedural complexity was higher in the DES era, nevertheless, risk for target vessel revascularization and major adverse cardiac event at 3 years were significantly lower in women treated with DES than in women treated with BMS (adjusted hazard ratio [HR] for target vessel revascularization: 0.52 [95% confidence interval (CI): 0.36 to 0.75], adjusted HR for major adverse cardiac event: 0.63 [95% CI: 0.48 to 0.83]).

CONCLUSIONS

Although women had worse baseline characteristics, no differences in 3-year outcomes were observed between men and women. Compared with BMS use, DES use has decreased revascularization rate equally in women and men.

Morbidity and mortality following coronary artery bypass graft surgery in patients with cirrhosis: a population-based study

BACKGROUND

The risk of cardiac surgery in patients with cirrhosis is poorly defined. Our objective was to describe outcomes of coronary artery bypass graft (CABG) surgery in cirrhotic patients from a population-based perspective.

METHODS

We analysed the 1998-2004 Nationwide In-patient Sample to identify patients hospitalized for CABG surgery. The effect of cirrhosis on mortality, complications, length of stay (LOS) and charges was evaluated using logistic regression models.

RESULTS

Between 1998 and 2004, there were 403 094 CABG admissions; 711 patients (0.2%) had cirrhosis. The average annual number of surgeries increased 4.2% [95% confidence interval (CI) 0.7-7.8] in cirrhotic patients, but decreased 5.5% (3.4-7.5) in non-cirrhotic patients. Patients with cirrhosis had an increased risk of mortality [17 vs. 3%; adjusted odds ratio (OR) 6.67; 95% CI 5.31-8.31], complications [43 vs. 28%; OR 1.99 (95% CI 1.72-2.30)] and greater LOS and charges (P<0.0001). Predictors of mortality included age over 60 (OR 2.21; 95% CI 1.31-3.73), female gender (OR 1.92; 95% CI 1.08-3.41), ascites (OR 3.80; 95% CI 1.95-7.39) and congestive heart failure (OR 1.75; 95% CI 1.08-2.84). Hospital volume and off-pump CABG did not affect mortality.

CONCLUSIONS

Patients with cirrhosis have an increased risk of morbidity and mortality following CABG surgery. Additional studies are necessary to refine risk stratification in this high-risk patient population.

Risk-taking attitudes and their association with process and outcomes of cardiac care: a cohort study

BACKGROUND

Prior research reveals that processes and outcomes of cardiac care differ across sociodemographic strata. One potential contributing factor to such differences is the personality traits of individuals within these strata. We examined the association between risk-taking attitudes and cardiac patients' clinical and demographic characteristics, the likelihood of undergoing invasive cardiac procedures and survival.

METHODS

We studied a large inception cohort of patients who underwent cardiac catheterization between July 1998 and December 2001. Detailed clinical and demographic data were collected at time of cardiac catheterization and through a mailed survey one year post-catheterization. The survey included three general risk attitude items from the Jackson Personality Inventory. Patients' (n = 6294) attitudes toward risk were categorized as risk-prone versus non-risk-prone and were assessed for associations with baseline clinical and demographic characteristics, treatment received (i.e., medical therapy, coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI)), and survival (to December 2005).

RESULTS

2827 patients (45%) were categorized as risk-prone. Having risk-prone attitudes was associated with younger age (p < .001), male sex (p < .001), current smoking (p < .001) and higher household income (p < .001). Risk-prone patients were more likely to have CABG surgery in unadjusted (Odds Ratio [OR] = 1.21; 95% CI 1.08-1.36) and adjusted (OR = 1.18; 95% CI 1.02-1.36) models, but were no more likely to have PCI or any revascularization. Having risk-prone attitudes was associated with better survival in an unadjusted survival analysis (Hazard Ratio [HR] = 0.78 (95% CI 0.66-0.93), but not in a risk-adjusted analysis (HR = 0.92, 95% CI 0.77-1.10).

CONCLUSION

These exploratory findings suggest that patient attitudes toward risk taking may contribute to some of the documented differences in use of invasive cardiac procedures. An awareness of these associations could help healthcare providers as they counsel patients regarding cardiac care decisions.

Patient and hospital characteristics associated with claims and compensations for patient injuries in coronary artery bypass grafting in Finland

OBJECTIVES

To analyse the association between individual patients' risk factors and rates of claims and compensations for patient injuries in an insurance scheme in which proof of negligence is not required. And to explore whether either hospital productivity or volume of procedures is related to claims and compensation rates.

METHODS

A two-step sequential logistic regression was applied on data collected from administrative registers. It included 17,834 patients who had undergone coronary artery bypass grafting at public hospitals in Finland between 1998 and 2002. The main outcome measure was the odds of claiming and receiving compensation.

RESULTS

Men were less likely to claim compensation (odds ratio [OR] 0.66; 95% confidence interval 0.54-0.81), but among those having claimed were more likely to receive compensation (OR 2.08; 1.15-3.75) than women. Patients with a co-morbidity were more likely to claim (OR 1.29; 1.06-1.57), but among those having claimed were less likely to receive compensation (OR 0.52; 0.31-0.86) than those without a co-morbidity. Advanced age reduced the probability of claiming (OR 0.71; 0.52-0.96).

CONCLUSIONS

Although high-risk patients file a claim more frequently than low-risk patients, the latter have a higher probability of getting their claims accepted and receiving compensation. This risk pattern is probably a reflection of compensation practices related to patient injuries involving an infection.

Coronary heart disease in women: less extensive disease and improved long-term survival compared to men

OBJECTIVES

The aim of the study was to compare extent of coronary disease and subsequent long-term survival in women compared to men adjusted for baseline differences in demographics and morbidity.

DESIGN

In the database at Feiring Heart Clinic 18 767 patients had a coronary angiographic examination in the period from March 1999 to December 31, 2006. Their survival status as of May 31, 2007 was ascertained through the Norwegian National Registry. Survival was compared using age stratified analyses and Cox regression adjusting for baseline differences.

RESULTS

Significantly more women than men had no coronary disease (28.7 vs. 10.5%, p <0.001), while three vessel disease was more frequently present in men (38.7 vs. 21.8%, p <0.001), as judged by coronary angiography. Covariate adjusted survival was significantly better in women compared to men with an overall hazard ratio of 1.29 (p <0.001), but with no significant difference in the subgroup with high left ventricular end diastolic pressure.

CONCLUSIONS

At the time of referral to invasive examination women had less extensive coronary artery disease than men as judged by coronary angiography and improved long-term survival when baseline differences were accounted for.

Decreasing number of deaths of infants with hypoplastic left heart syndrome

OBJECTIVE

To assess mortality rates and demographic characteristics for infants with hypoplastic left heart syndrome (HLHS) in California.

STUDY DESIGN

We used California death registry files from 1990 to 2004 to compare overall mortality and demographic characteristics between infants with HLHS (n = 856) who received surgical intervention and those who received comfort care. The California discharge database was used to calculate the annual incidence of disease and survival rates for infants with HLHS undergoing surgery between 1995 and 1999.

RESULTS

The annual number of deaths for infant with HLHS decreased by nearly 50% over the study period, even though the incidence of the disease remained constant during this period. For all deaths, the proportion of infants receiving comfort care decreased significantly over time compared with those infants who underwent surgery. Although the total number of deaths in infants with HLHS who underwent surgical intervention increased, the mortality rate for this cohort decreased. Interstage unexpected mortality and the median age at death both increased in the infants who underwent surgery.

CONCLUSIONS

Over the study period of 1990 to 2004 in California, fewer families chose comfort care for infants diagnosed with HLHS, and the number of deaths for those infants who underwent surgical intervention increased. These changes likely reflect improved treatment outcomes and an increased number of families desiring surgical intervention in higher-risk infants.

Gender Influence on Hospital Mortality after Coronary Artery Bypass Surgery

There is still controversy about the influence of gender on hospital mortality after coronary artery bypass grafting. We analyzed various risk factors in 1,258 patients undergoing isolated on-pump coronary artery bypass, of whom 19 (1.5%) died in hospital. There were 937 men (74.5%) and 321 women (25.5%). Compared to men, women were older with a higher mean body mass index, twice as many were hypertensive and diabetic, and they had higher serum cholesterol and triglycerides. Men smoked more, had lower ejection fractions, more myocardial infarctions and poorer functional status. Female sex, congestive heart failure, low ejection fraction, diabetes, previous percutaneous interventions and chronic lung disease were more prevalent among the patients who died. These factors were used to form a logistic regression model in which sex did not have an independent influence on hospital mortality. The difference between men and women can be explained by differences in risk factor profile.

A systematic review of gender differences in mortality after coronary artery bypass graft surgery and percutaneous coronary interventions

Gender differences exist in outcomes, particularly early mortality, for percutaneous interventions (PCI) and coronary artery bypass graft surgery (CABG). Better understanding of this issue may target areas for improvement for all patients undergoing revascularization. Therefore, we summarized the evidence on gender differences in PCI and CABG outcomes, particularly early mortality, and mediators of this difference. Using the key terms "women" or "gender," "revascularization," "coronary artery bypass," "angioplasty," "stent," and "coronary intervention," we searched MEDLINE from 1985 to 2005 for all randomized controlled trials (RCTs) and registries reporting outcomes by gender. Bibliographies and the Web sites of cardiology conferences were also reviewed. The literature was examined to identify gender differences in outcomes and mediators of these differences. We identified 23 studies reporting outcomes by gender for CABG and 48 studies reporting outcomes by gender for PCI. The majority of studies noted greater in-hospital mortality in women than in men, with mortality differences resolving with longer follow-up. Early mortality differences were reduced but not consistently eliminated after adjustment for comorbidities, procedural characteristics, and body habitus. Power to detect gender differences after multivariate adjustment was limited by declining mortality rates and small sample size. Gender was an independent risk factor for complications after both CABG and PCI. Women experience greater complications and early mortality after revascularization. Future exploration is needed of gender differences in quality of care and benefit from combinations of stenting and antiplatelet, and anticoagulant medications in order to optimize treatment.

The role of sex-specific results reporting in cardiovascular disease

Cardiovascular disease (CVD) is the primary cause of death among women worldwide. In the United States, more women than men die of CVD every year. Research has shown that there are important sex differences in terms of prevention, diagnosis, treatment, and outcomes in patients with CVD. Although women are being included in clinical trials in increasing numbers, lack of knowledge about sex differences persists because sex-specific analysis and reporting of sex-specific results remains limited. This knowledge gap limits the ability of health care professionals to provide optimal care for both women and men. Ongoing support and encouragement is needed for both the inclusion of sufficient numbers of women in clinical trials and for the reporting of sex-specific results of CVD trials. This increased knowledge and awareness can then be used to optimize high quality care for men and women.

Effect of comorbid and fatal coexistent conditions on sex and race differences in vascular surgical mortality

Many previous studies of vascular procedures have found sex and race differences in surgical mortality that were attributed to differential prevalence of comorbidity. Adjustment for selected comorbid conditions does not entirely remove bias. In addition to adjustments for other covariates, surgical mortality ratios in this study were adjusted for coexistent conditions that caused postoperative death but were unrelated to the procedure. The adjusted mortality was, therefore, attributable to the procedure. Medicare administrative and death certificate data on beneficiaries aged 65-99 years who resided in Indiana and Kentucky and who had 6,016 major vascular procedures in 1994-1997 were used. In Cox proportional hazard models, male-to-female and nonwhite-to-white surgical mortality ratios were adjusted for age, sex, or race; weighted Charlson comorbidity score; length of hospital stay; and fatal coexisting conditions (FCCs). Altogether, 3,333 patients died within 30 postoperative days. There were sex and/or race differences in mortality caused by aortic aneurysm, stroke, and diabetes (P < 0.05). Unadjusted, all-cause 30-day mortality was higher in women and nonwhite patients than in men and white patients following coronary artery bypass graft (CABG) procedure (P < 0.03). Mortality following all non-CABG procedures combined was lower in women than in men (P < 0.02). In multivariate analyses, 30-day mortality following CABG, adjusted for covariates, was lower in men than in women (hazard ratio [HR] = 0.88, 95% confidence interval [CI] 0.79-0.98), but there was no sex difference after adjustment for only FCC (HR = 0.94, 95% CI 0.85-1.05). Mortality following all non-CABG procedures combined was higher in men than in women, but this difference was insignificant after adjustment for comorbidity and/or FCC (HR = 1.05, 95% CI 0.93-1.17). Age- and sex-adjusted 30-day mortality following CABG was higher in nonwhite patients than in white patients (HR = 1.37, 95% CI 1.08-1.74), and this race difference persisted after further adjustments. There were no significant sex or race differences in surgical mortality following carotid endarterectomy, non-CABG thoracoabdominal procedures, or procedures in the limbs. Adjustments for covariates did not alter race difference in post-CABG surgical mortality. Adjustment for comorbid conditions slightly affected sex differences in mortality following CABG and all non-CABG procedures combined, but adjustment for FCC reduced these differences to insignificant levels.

Do women spend longer on wait lists for coronary bypass surgery? Analysis of a population-based registry in British Columbia, Canada

Background

Studies have shown patients who are delayed for surgical cardiac revascularization are faced with increased risks of symptom deterioration and death. This could explain the observation that operative mortality among persons undergoing coronary artery bypass surgery (CABG) is higher among women than men. However, in jurisdictions that employ priority wait lists to manage access to elective cardiac surgery, there is little information on whether women wait longer than men for CABG. It is therefore difficult to ascertain whether higher operative mortality among women is due to biological differences or to delayed access to elective CABG.

Methods

Using records from a population-based registry, we compared the wait-list time between women and men in British Columbia (BC) between 1990 and 2000. We compared the number of weeks from registration to surgery for equal proportions of women and men, after adjusting for priority, comorbidity and age.

Results

In BC in the 1990s, 9,167 patients aged 40 years and over were registered on wait lists for CABG and spent a total of 136,071 person-weeks waiting. At the time of registration for CABG, women were more likely to have a comorbid condition than men. We found little evidence to suggest that women waited longer than men for CABG after registration, after adjusting for comorbidity and age, either overall or within three priority groups.

Conclusion

Our findings support the hypothesis that higher operative mortality during elective CABG operations observed among women is not due to longer delays for the procedure.

Hospital mortality in acute coronary syndrome: differences related to gender and use of percutaneous coronary procedures

Background

To identify differences among men and women with acute coronary syndrome in terms of in-hospital mortality, and to assess whether these differences are related to the use of percutaneous cardiovascular procedures.

Methods

Observational study based on the Minimum Basic Data Set. This encompassed all episodes of emergency hospital admissions (46,007 cases, including 16,391 women and 29,616 men) with a main diagnosis of either myocardial infarction or unstable angina at 32 hospitals within the Andalusian Public Health System over a four-year period (2000–2003). The relationship between gender and mortality was examined for the population as a whole and for stratified groups depending on the type of procedures used (diagnostic coronary catheterisation and/or percutaneous transluminal coronary angioplasty). These combinations were then adjusted for age group, main diagnosis and co-morbidityharlson score).

Results

During hospitalisation, mortality was 9.6% (4,401 cases out of 46,007), with 11.8% for women and 8.3% for men. There were more deaths among older patients with acute myocardial infarction and greater co-morbidity. Lower mortality was shown in patients undergoing diagnostic catheterisation and/or PTCA. After adjusting for age, diagnosis and co-morbidity, mortality affected women more than men in the overall population (OR 1.14, 95% CI: 1.06–1.22) and in the subgroup of patients where no procedure was performed (OR 1.16, 95% CI: 1.07–1.24). Gender was not an explanatory variable in the subgroups of patients who underwent some kind of procedure.

Conclusion

Gender has not been associated to in-hospital mortality in patients who undergo some kind of percutaneous cardiovascular procedure. However, in the group of patients without either diagnostic catheterisation or angioplasty, mortality was higher in women than in men.

Risk factors for red cell transfusion in adults undergoing coronary artery bypass surgery: a systematic review

BACKGROUND AND OBJECTIVE

Identifying factors that can predict adults at high risk of receiving red blood cell transfusion during coronary artery bypass graft (CABG) surgery may aid in more efficient blood banking practices and may tailor blood conservation strategies for these adult patients. The objective was to identify clinical factors associated with increased red cell transfusion in adults undergoing CABG surgery.

METHODS

A systematic review of the MEDLINE and HealthSTAR databases from 1966 to December 2005 was conducted. Citations containing the medical subject heading or textwords 'coronary artery bypass graft', 'CABG' and 'cardiovascular surgery' were combined with the medical subject headings or textwords 'transfusion' and 'blood transfusion'.

RESULTS

A total of 2461 abstracts were retrieved. Twenty-one studies met the inclusion/exclusion criteria. Transfusion rates ranged from 7 to 97%. Several variables were identified that were associated with increased red cell transfusion rates including older age, female sex, low haemoglobin concentration or haematocrit value, renal insufficiency and urgent/emergent surgery. The strongest risk factor was the urgency of surgery (urgent or emergent surgery), which was associated with a 4x to 8x increase in transfusion rates compared to elective surgery. Increasing age and female sex increased the likelihood of transfusion by 1x to 3x and 2x, respectively.

CONCLUSIONS

Increasing patient age, female sex, lower preoperative haemoglobin levels, as well as the urgency of the CABG surgery were associated with higher transfusion rates. Identifying risk factors for transfusion may allow for targeted use of blood conservation strategies, improved efficiency in blood utilization and informing adults at risk of transfusion.

24-Hour In-hospital Mortality Predictions in Coronary Artery Bypass Grafting Patients

BACKGROUND

The purpose of this study was to determine the factors that can help predict risk of mortality in the first 24 h of coronary artery bypass grafting (CABG), because mortality within a few hours of surgery is a disastrous event for surgeons and the patient's family.

METHODS

The study population consisted of 120 in-hospital mortality cases (1.07%) from 11,183 patients who underwent CABG from February 2002 to February 2006 by the same group of surgeons in a referral center. One group consisted of 40/120 (about 33.3%) patients who died during the first 24 h after surgery. The second group consisted of 80/120 patients (66.7%) who died between the 2(nd) and 30(th) day postoperatively. A set of data was gathered from the surgery database of the hospital and analyzed in a univariate model.

RESULTS

Among the studied variables, only the following factors proved to be significant: previous percutaneous transluminal coronary angioplasty (PTCA), previous cerebrovascular accident (CVA), cardiopulmonary bypass (CBP) time, and postoperative atrial fibrillation (AF) (p </=0.05).

CONCLUSIONS

This study revealed that influencing factors in 24-h in-hospital mortality are previous PTCA, previous CVA, CBP time, and postoperative AF. It is interesting that influencing factors in global 30-day hospital mortality such as body mass index, diabetes mellitus, preoperative arrhythmia, ejection fraction, history of previous CABG and resuscitation, or catastrophic states like poor runoff coronary vessels, triple vessel disease or associated procedures like valve surgery were not significant in the first 24-h mortality when comparing with in-hospital mortality in this study.

Significant Improvement in Short-Term Mortality in Women Undergoing Coronary Artery Bypass Surgery (1991 to 2004)

OBJECTIVES

This study sought to evaluate gender differences and trends in 30-day mortality after coronary artery bypass surgery (CABG).

BACKGROUND

Evidence for gender differences in short-term mortality after CABG is conflicting. Many studies were from single centers, included highly selected populations, or had limited clinical information for adequate covariate adjustment. We undertook a population-based analysis using detailed clinical data on all adults undergoing CABG in the province of British Columbia, Canada.

METHODS

The study population comprised all residents 20 years and older who underwent isolated CABG between 1991 and 2004. Multiple logistic regression was used to examine the association between gender and 30-day mortality; time trend analysis was conducted by Mantel-Haenszel chi-square test.

RESULTS

The study cohort comprised 20,229 men and 4,983 women. Women were older and had more comorbid conditions than men, but had better ejection fractions and less extensive coronary disease. Thirty-day mortality decreased significantly in men (2.4% to 1.9%) and women (5.6% to 1.9%) over the 14-year study period. Overall, 30-day mortality was significantly higher in women (3.6% vs. 2.0%, p < 0.001), and adjustment for baseline differences did not remove this difference (odds ratio 1.42, 95% confidence interval 1.15 to 1.75). Adjustment for body surface area, an intrinsic gender difference, further attenuated the relationship (odds ratio 1.26, 95% confidence interval 0.96 to 1.64).

CONCLUSIONS

The 30-day mortality after CABG decreased significantly between 1991 and 2004, especially in women, suggesting that the gender difference in short-term outcomes is diminishing. The overall 42% higher mortality risk in women seems to be partially mediated through body surface area, a surrogate for vessel size.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.