Is sex a factor in determining operative risk for aortocoronary bypass graft surgery?

Gender differences in the association between cardiovascular diseases and major depressive disorder among older adults in India

Background

Despite the global disease burden associated with the co-occurrence of cardiovascular diseases (CVDs) and depression, depression remains underdiagnosed and undertreated in the CVD population, especially among older adults in India. As such, this study examines (1) the association between single and multiple CVDs and major depressive disorder among older Indians; (2) whether this association is mediated by older adults' self-rated health and functional limitations; and (3) whether these associations vary for older men and women.

Methods

Data come from the 2017-18 wave 1 of the Longitudinal Ageing Study in India. Multivariable logistic regression is used to explore the association between CVDs and major depressive disorder among older men and women. The Karlson-Holm-Breen (KHB) method is used to examine the mediation effects of self-rated health and functional difficulties in the observed associations.

Results

Overall, 5.08% of the older adults had multiple CVDs. Older women (9.71%) had a higher prevalence of major depressive disorder compared to men (7.50%). Multiple CVDs were associated with greater odds of major depressive disorder after adjusting the potential covariates (adjusted odds ratio [AOR]: 1.49; 95% confidence interval [CI]: 1.10-2.00). Older men with multiple CVDs had a greater risk of major depressive disorder (AOR: 1.64; 95% CI: 1.05-2.57) relative to women with CVDs (AOR: 1.39; 95% CI: 0.93-2.08). The association between multiple CVDs and depression was mediated by self-rated health (34.03% for men vs. 34.55% for women), ADL difficulty (22.25% vs. 15.42%), and IADL difficulty (22.90% vs. 19.10%).

Conclusions

One in five older Indians with multiple CVDs reports major depressive disorder, which is three times more common than the prevalence of depressive disorder in older adults without CVDs. This association is attenuated by self-rated health and functional limitations. Moreover, these associations are more pronounced in older men relative to older women. These findings depart from prior inferences that men with CVDs are less psychologically distressed than their female counterparts. Moreover, the findings underscore the importance of gender-specific approaches to interventions and therapeutics for CVD-related mental health.

Mediators of gender effects on depression among cardiovascular disease patients in Palestine

BACKGROUND

Among patients suffering from coronary heart disease (CHD) and comorbid depression, women experience a higher burden compared to men. Little is known on the characteristics that differentiate men and women with both diseases and whether these factors mediate gender effects on depression. This study assessed whether women are more likely to suffer from depression and which characteristics mediate gender effects on depression among a cardiac population in Palestine, specifically addressing the role of post-traumatic stress disorder (PTSD).

METHODS

Using a cross-sectional design, patients consecutively admitted with a CHD to one of the four main hospitals in Nablus, Palestine, were interviewed using a structured questionnaire with validated instruments. Data was also obtained from hospital medical records. Patients were assessed for depression using the Cardiac Depression Scale (CDS). Bivariate analysis was conducted to compare characteristics of women and men with and without depressive symptoms. Mediators (direct and indirect effects) of the association between gender and depression were evaluated using a structural equation model (SEM).

RESULTS

Women were more likely to suffer from severe depression than men (28.7% vs. 18.8%). Female gender was positively associated with higher PTSD symptoms, comorbidities, somatic symptoms and income, and with lower resilience, self-esteem, quality of life, education, prevalence of smoking and physical activity. Structural equation modeling revealed negative indirect effects of gender on depression (CDS score) through resilience, self-esteem and physical activity, whereas positive indirect effects of gender on depression were observed through PTSD, comorbidities, somatic symptoms and smoking. There was no direct effect of gender on depression.

CONCLUSION

This study found a higher prevalence of severe depression in female patients with cardiac disease compared to male cardiac patients. Our findings provide novel information on mediating factors of the association between gender and depression among cardiac patients, in particular PTSD. The results emphasize the need for further research on potential mediating factors that could account for gender differences in depression and the need to provide support programs for female patients with comorbid CHD and depression to improve their psycho-social well-being.

Ischemia and reperfusion injury following cardioplegic arrest is attenuated by age and testosterone deficiency in male but not female mice

BACKGROUND

Cardiovascular disease increases with age in both sexes. Treatment can require cardiac surgery, where the hearts are pre-treated with protective cardioplegic solution before ischemia and reperfusion (I/R). While endogenous estrogen is beneficial in I/R, whether testosterone is involved is uncertain and whether age modifies responses to I/R is unclear. We investigated sex- and age-specific differences in I/R injury in the hearts pre-treated with clinically relevant cardioplegic solution.

METHODS

The hearts were isolated from young (6-9 months) and old (20-28 months) mice of both sexes and perfused (Langendorff) with Krebs-Henseleit buffer (15 min, 37 °C), followed by St. Thomas' two cardioplegia (6 min, 6-7 °C), global ischemia (90 min, 23-24 °C), and reperfusion (30 min, 37 °C). The hearts were perfused with triphenyltetrazolium chloride to quantify infarct area. Testosterone's role was investigated in gonadectomized (GDX, 6-9 months) male mice; serum testosterone and estradiol were measured with ELISA assays.

RESULTS

Left ventricular developed pressure (LVDP) recovered to 67.3 ± 7.4% in the old compared to 21.8 ± 9.2% in the young male hearts (p < 0.05). Similar results were seen for rates of pressure development (+dP/dt) and decay (-dP/dt). Infarct areas were smaller in the old male hearts (16.6 ± 1.6%) than in the younger hearts (55.8 ± 1.2%, p < 0.05). By contrast, the hearts from young and old females exhibited a similar post-ischemic functional recovery and no age-dependent difference in infarcts. There was a sex difference in the young group, where ventricular function (LVDP, +dP/dt, -dP/dt) recovered better and infarcts were smaller in females than males. Estradiol levels were highest in young females. Testosterone was high in young males but low in females and old males, which suggested beneficial effects of low testosterone. Indeed, the hearts from GDX males exhibited much better recovery of LVDP in reperfusion than that from intact males (values were 64.4 ± 7.5 % vs. 21.8 ± 9.2%; p < 0.05). The GDX hearts also had smaller infarcts than the hearts from intact males (p < 0.05).

CONCLUSIONS

Although age had no effect on susceptibility to I/R injury after cardioplegic arrest in females, it actually protected against injury in older males. Our findings indicate that low testosterone may be protective against I/R injury following cardioplegic arrest in older males.

The Influence of Sex on Cardiac Physiology and Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of death world-wide. Most of treatment strategies were based on studies conducted on male patients. Studies have shown that significant differences exist between the two sexes in the development of CVD. There are certain differences between men and women in the structure and physiological functions of the heart such as left ventricular mass index, resting heart rate, and contractile function. Accordingly, the pathological features of the heart such as the extend of hypertrophy, fibrosis, and remodeling are also different. In addition, different genders also affect clinical symptoms, responses to treatment and prognosis in the development of CVD. Therefore, it is important to take these differences into consideration when design treatment options for men and women.

Does a similar procedure result in similar survival for women and men undergoing isolated coronary artery bypass grafting?

OBJECTIVES

To (1) identify sex-related differences in risk factors and revascularization strategies for patients undergoing coronary artery bypass grafting (CABG), (2) assess whether these differences influenced early and late survival, and (3) determine whether clinical effectiveness of the same revascularization strategy was influenced by sex.

METHODS

From January 1972 to January 2011, 57,943 adults-11,009 (19%) women-underwent primary isolated CABG. Separate models for long-term mortality were developed for men and women, followed by assessing sex-related differences in strength of risk factors (interaction terms).

RESULTS

Incomplete revascularization was more common in men than women (26% vs 22%, P < .0001), but women received fewer bilateral internal thoracic artery (ITA) grafts (4.8% vs 12%; P < .0001) and fewer arterial grafts (68% vs 70%; P < .0001). Overall, women had lower survival than men after CABG (65% and 31% at 10 and 20 years, respectively, vs 74% and 41%; P ≤ .0001), even after risk adjustment. Incomplete revascularization was associated equally (P > .9) with lower survival in both sexes. Single ITA grafting was associated with equally (P = .3) better survival in women and men. Although bilateral ITA grafting was associated with better survival than single ITA grafting, it was less effective in women-11% lower late mortality (hazard ratio, 0.89 [0.77-1.022]) versus 27% lower in men (hazard ratio, 0.73 [0.69-0.77]; P = .01).

CONCLUSIONS

Women on average have longer life expectancies than men but not after CABG. Every attempt should be made to use arterial grafting and complete revascularization, but for unexplained reasons, sex-related differences in effectiveness of bilateral arterial grafting were identified.

Sex Differences in Mortality After CABG Surgery

INTRODUCTION

Numerous studies have shown that women undergoing coronary artery bypass graft surgery present higher mortality rate during hospitalization, and often complications when compared to men.

OBJECTIVE

To compare the mortality of men and women undergoing coronary artery bypass graft surgery and identify factors related to differences occasionally found.

METHODS

Retrospective cohort study conducted with 215 consecutive patients who underwent coronary bypass surgery.

RESULTS

Women had a higher average age. Low body surface and dyslipidemia were more prevalent in women (1.65 vs. 1.85, P <0.001: 53% vs. 30%, P =0.001), whereas history of smoking and previous myocardial infarction were more prevalent in men (35% vs.14.7%, P =0.001; 20% vs. 2.7%, P =0.007). Regarding complications in the postoperative period, there was a higher rate of blood transfusions in women. The overall mortality rate was 5.6%, however there was no statistically significant difference in mortality between men and women. It was observed that among the patients who died, the average body surface area was lower than that of patients who did not have this complication.

CONCLUSION

There was no difference in mortality between the sexes after coronary artery bypass graft in this service.

Off-pump coronary revascularization: A potential benefit for female patients?

Coronary artery disease is one of the leading causes of illness for both men and women. However, women are 3 times more likely to die for coronary artery disease as they are of breast cancer. There are an increasing prevalence of coronary artery disease in women and thus facing the need for surgical revascularization. It has long being accepted that women carry a high risk of coronary surgery than men. Many investigators have suggested that female itself is predictive of poor outcome after on pump coronary surgery. We thought to search the litlature to investigate whether women who undergo off-pump surgery receive any benefits compared with women undergoing on-pump surgery.

Comparison by meta-analysis of mortality after isolated coronary artery bypass grafting in women versus men

Short- and long-term mortality in women who undergo coronary artery bypass grafting (CABG) has been evaluated in multiple studies with conflicting results. The investigators conducted a meta-analysis of all existing studies to evaluate the impact of female gender on mortality in patients who undergo isolated CABG. A comprehensive search of studies published through May 31, 2012 identified 20 studies comparing men and women who underwent isolated CABG. All-cause mortality was evaluated at short-term (postoperative period and/or at 30 days), midterm (1-year), and long-term (5-year) follow-up. Odds ratios (ORs) and 95% confidence interval (CIs) were calculated using a random-effects model. A total of 966,492 patients (688,709 men [71%], 277,783 women [29%]) were included in this meta-analysis. Women were more likely to be older; had significantly greater co-morbidities, including hypertension, diabetes mellitus, hyperlipidemia, unstable angina, congestive heart failure, and peripheral vascular disease; and were more likely to undergo urgent CABG (51% vs 44%, p <0.01). Short-term mortality (OR 1.77, 95% CI 1.67 to 1.88) was significantly higher in women. At midterm and long-term follow-up, mortality remained high in women compared with men. Women remained at increased risk for short-term mortality in 2 subgroup analyses including prospective studies (n = 41,500, OR 1.83, 95% CI 1.59 to 2.12) and propensity score-matched studies (n = 11,522, OR 1.36, 95% CI 1.04 to 1.78). In conclusion, women who underwent isolated CABG experienced higher mortality at short-term, midterm, and long-term follow-up compared with men. Mortality remained independently associated with female gender despite propensity score-matched analysis of outcomes.

Racial disparities in left main stenting: insights from a real world inner city population

BACKGROUND

Left main coronary artery (LMCA) disease is associated with significant cardiovascular mortality. The data on patient characteristics' predicting outcomes after LMCA revascularization is sparse.

METHODS

A retrospective study of 227 patients with LMCA disease documented on coronary angiography from March 2000 to December 2008. Data included demographic variables, co-morbidities, cardiac function, and medications. Race was self-identified. The study outcome was a composite end-point including myocardial infarction (MI) and all-cause mortality. Cox proportional hazard analysis was performed to study the effect of various patient attributes including race and gender on the composite end-point.

RESULTS

Baseline characteristics were specifically compared between individuals who had the study outcome versus those who did not. Mean age was higher in the group with study outcomes when compared to the group without any outcomes (64.3 ± 11.8 years versus 59.2 ± 13.6 years; p = 0.013). After the final multivariate regression analysis, only African American (AA) race and age were found to be independent predictors of adverse cardiac outcome at the end of the first year (race-hazard ratio (HR) 3.82, 95% confidence interval (CI) 1.38-10.62, p = 0.010; age-HR 1.08, 95% CI 1.04-1.13, p < 0.001) and at the end of the study (race-HR 2.71, 95% CI 1.44-5.10, p = 0.002; age-HR 1.03, 95% CI 1.01-1.08, p = 0.017).

CONCLUSION

In our study of patients with unprotected LMCA disease, AA race, and age were significantly predictive of poor prognosis following revascularization, while gender had no predictive value in prognosticating cardiovascular mortality.

Relationship between gender and in-hospital morbidity and mortality after coronary artery bypass grafting surgery in an Iranian population

Background:

Many previous studies have investigated the influence of gender on coronary artery bypass grafting surgery (CABG) outcomes. Despite the great volume of reports on this issue, it is still not clear whether it is the gender of the patient or pre-existing comorbid conditions that is the best predictor for the different outcomes seen between men and women. Multiple studies have shown that women are at higher risk of postoperative complications than men, particularly in the perioperative period.

Objectives:

The goal of this study was to determine whether sex differences exist in preoperative variables between men and women, and to evaluate the effect of gender on short-term mortality and morbidity after CABG in an Iranian population.

Patients and Methods:

Data were collected prospectively from 690 consecutive patients (495 men and 195 women) who underwent isolated CABG. Preoperative, intraoperative, and postoperative variables, major complications and death were compared between the male and female patients until hospital discharge using multivariate analysis.

Results:

Women were older (P = 0.020), had more diabetes (P = 0.0001), more obesity (P = 0.010), a higher New York Heart Association functional class (P = 0.030), and there was less use of arterial grafts (P = 0.016). Men had more tobacco smokers (P = 0.0001) and lower preoperative ejection fractions (EF) (P = 0.030). After surgery, women had a higher incidence of respiratory complications (P = 0.003), higher creatine kinase (CK) – MB levels (P = 0.0001), and higher inotropic support requirements (P = 0.030). They also had a higher incidence of decreased postoperative EF versus preoperative values (P = 0.020). The length of ICU stay, incidence of return to ICU and postoperative death, were similar between men and women. Nevertheless, after adjusting for age and diabetes, female gender was still independently associated with higher morbidity in patients over 50 years of age.

Conclusions:

Women had more risk factors, comorbidities, and postoperative complications. Women older than 50 years of age were at a higher risk of postoperative complications than men. This difference decreased with younger age. In-hospital mortality rates were not influenced by sex, as there was no difference found between the two groups (2.5% women vs. 2.2% men; P > 0.05).

Brown fat like gene expression in the epicardial fat depot correlates with circulating HDL-cholesterol and triglycerides in patients with coronary artery disease

BACKGROUND

Recent evidence indicates that epicardial adipose tissue (EAT) expresses uncoupling protein-1 (UCP1), a marker of brown adipocytes. However, the putative effects of the presence of brown adipocytes in EAT remain unknown.

METHODS

The mRNA expression of genes related to brown adipocyte-mediated thermogenesis was measured in the fat samples collected from the epicardial-, mediastinal- and subcutaneous-depots of patients undergoing coronary artery bypass grafting. Both univariate and multivariate analyses were then utilized to determine any association between gene expression and the anthropometrics and fasting blood chemistries of these patients.

RESULTS

EAT exhibited significantly higher expression of UCP1 and cytochrome c oxidase subunit-IV (COX-IV) compared to mediastinal- and subcutaneous-fat depots (P ≤ 0.05). EAT expression of UCP1 (r=0.50), COX-IV (r=0.37) and lipoprotein lipase (LPL) (r=0.58) positively associated with circulating levels of HDL-cholesterol (P ≤ 0.05). In addition, EAT expression of LPL, acyl coA dehydrogenase-short, -medium and -long chain genes associated negatively with circulating TG levels (P ≤ 0.05).

CONCLUSIONS

Abundance of UCP-1 in the EAT relative to other fat depots confirms the presence of brown adipocytes in human EAT. Furthermore, the correlations among the EAT expression of thermogenesis-related genes with the circulating HDL and TG levels indicate that presence of active brown adipocytes shares a functional association with the circulating plasma lipids in humans.

Gender influence in isolated coronary artery bypass graft surgery: a propensity match score analysis of early outcomes

INTRODUCTION

The female gender has been shown as high-risk factor for mortality and morbidity. We sought to assess the influence of female gender on coronary artery bypass graft (CABG) surgery from our own experience.

METHODS

This is a retrospective analysis of prospectively collected database from a single centre. Patients were grouped according to gender and potential differences in pre-operative, intra-operative and post-operative factors were explored. Significant high-risk factors were then fitted in a multivariate model to account for differences in predicting gender influence on surgical outcomes.

RESULTS

Two thousand eight hundred and four consecutive patients underwent isolated first-time CABG between February 2000 and December 2008; 562 (20%) patients were females. Pre-operatively, females were more likely to have significant comorbidities (age, congestive cardiac failure, hypercholesterolemia, hypertension, ischemic heart disease, peripheral vascular disease, pre-op arrhythmias, small body surface area and poor ejection fraction (p < 0.001)) consistent with higher Euroscore (p > 0.0001) and more urgent surgery (p < 0.002). Intra-operatively, they showed less extent pattern of disease requiring less bypass and cross-clamp time (p < 0.001). Observed surgical mortality was significantly higher in females (3.6 vs. 2.1%, p < 0.042); however, after adjusting for propensity score and significant factors identified in multivariate models, females only independently predicted a higher wound infection, lower neurological complications, lower rate of re-sternotomy, longer hospital stay and post-surgery stay (p < 0.01).

CONCLUSIONS

Despite higher risk profile and higher observed surgical mortality, early outcomes in females were similar to their matched males' counterpart in isolated CABG surgery. Females were associated with higher incidence of wound infections but lower rate of neurological complications.

Sex and gender differences in coronary artery disease

Significant sex differences exist between men and women with regard to coronary artery disease. Most notably, this lethal disease kills more women than men each year and remains the leading cause of death for both men and women. Women and men clearly have different risk profiles when diagnosed with coronary artery disease and fare much differently after myocardial infarction and coronary artery bypass grafting. This review summarizes the sex differences in clinical presentation, diagnosis, and the surgical treatment of coronary artery disease between men and women; and potential multifactorial reasons for sex disparities are suggested.

Relative survival after CABG surgery is poorer in women and in patients younger than 70 years at surgery

OBJECTIVE

The difference in survival between genders after coronary artery bypass surgery (CABG) have been studied with varying results. We wanted to investigate gender and age specific relative survival in the CABG population. Risk factors increasing hazard of death in female patients were isolated.

DESIGN

Retrospectively, 6699 primary isolated CABG procedures were investigated. Long-term survival compared to expected survival in the background population was described through Kaplan-Meier plots. Two subgroups of female patients were described through baseline characteristics, t-tests, odds ratio and multivariate analysis to investigate risk factors for death within one year after surgery.

RESULTS

Women had significantly decreased relative long-term survival compared to men in this study. Relative survival was lower in patients below 70 years of age at surgery with about the same gender difference. Low ejection fraction, left main stem stenosis and reduced renal function were found to increase risk of death within one year after CABG in women, while body size quantified by body surface area (BSA) did not.

CONCLUSION

Relative long-term survival after CABG was poorer in female compared to male patients. This tendency was kept or strengthened when only those less than 70 years of age at surgery were investigated. Lower female survival was most likely due to more comorbidity in female patients. Relative survival was lower in patients <70 years.

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.

Gender Differences in Diabetic Patients Following Coronary Artery Bypass Graft Surgery

OBJECTIVE

The objective was to examine the influence of gender in diabetic patients following coronary artery bypass graft (CABG) surgery.

METHODS

A study from an 11-year hospitalization cohort with prospective data collection was conducted. Included in the study were diabetic patients undergoing CABG surgery between October 1993 and May 2004 (n = 2781). Patients who underwent any surgery other than CABG or had a previous cardiac surgery were excluded. The study examined 25 risk factors and 14 outcome variables.

RESULTS

Twelve risk factors were found to be significantly different between male and female diabetic patients undergoing CABG. Correlation coefficients were computed among the 12 significant risk factors. Three main risk factors emerged: age 70 years or greater, abnormal LVH, and number of grafts. For outcome variables, females experienced more renal complications, intraoperative complications, longer hospital stay, and mortality. Logistic regression analysis showed that after controlling for age, LVH, and number of grafts, female diabetic patients undergoing CABG were more likely to experience intraoperative complications (OR 1.8, 95% CI 1.1-3.0, p = 0.025) and longer hospital stay (OR 0.99, 95% CI 0.97-0.99, p = 0.039). However, there was no significant difference between male and female diabetic patients after CABG surgery with renal complications (OR 1.39, 95% CI 0.95-2.1, p = 0.132) or mortality (OR 1.6, 95% CI 0.85-2.8, p = 0.153).

CONCLUSION

Female diabetic patients, when compared to male diabetic patients undergoing CABG, have significantly more intraoperative complications and longer hospital stays following surgery.

Gender-specific practice guidelines for coronary artery bypass surgery: perioperative management

Gender differences in coronary bypass surgery have been the focus of numerous publications in recent years. Unfortunately these publications have contradictions that leave surgeons with conflicting recommendations for care. To help resolve these inconsistencies, The Society of Thoracic Surgeons (STS) Workforce on Evidence-Based Surgery has carried out an objective review of published information in this field. The STS Workforce recognizes that there are important gender issues associated with referral bias, the impact of body size, psychosocial factors, and postoperative support, but the intent of this guideline is to focus specifically on perioperative management. As with all practice guidelines, our goal is to gather the most important information, analyze the information in a logical and unbiased fashion, and make recommendations based solely on the available evidence.

Gender risk differences for surgical site infections among a primary coronary artery bypass graft surgery cohort: 1995-1998

BACKGROUND

Knowledge about gender risk factors associated with acquiring postoperative coronary artery bypass graft (CABG) surgical site infections (SSIs) is limited.

OBJECTIVE

Our objective was to determine whether the incidence of SSIs during 30 days postsurgery was greater among females compared with males who undergo primary (first time) CABG.

METHODS

A retrospective cohort study of 3878 patients who had primary CABG surgery between January 1, 1995, and December 31, 1998, at a cardiovascular center in the American Southwest. Multivariate techniques were used to analyze outcome risk differences by gender.

RESULTS

The nosocomial SSI incidence rate among 957 females was 10.56%; among 2921 males, it was 7.57%; relative risk (RR) was 1.39 (95% confidence interval: 1.12-1.75), and Mantel-Haenszel chi2 test was 8.47 (P = .004). Four preoperative variables were independent predictors of acquiring SSI: female gender, diabetes, body mass index, and urgency of surgery.

CONCLUSION

Females were at greater risk for acquiring SSIs postprimary CABG surgery in this cohort. Also, preoperative, perioperative, and postoperative control of glucose levels in diabetics and preoperative reduction of weight in obese patients may help to reduce SSIs post-CABG surgery. More studies are needed to understand gender-associated risk of SSI after CABG surgery.

Assessment of independent predictors for long-term mortality between women and men after coronary artery bypass grafting: Are women different from men?

OBJECTIVE

The long-term mortality of coronary artery bypass grafting in women in not certain. The purpose of this study was to determine and compare risk factors for long-term mortality in women and men undergoing coronary artery bypass grafting.

METHODS

Between 1992 and 2002, 3760 consecutive patients (2598 men and 1162 women) underwent isolated coronary artery bypass grafting. Long-term survival data were obtained from the National Death Index (mean follow-up, 5.1 +/- 3.2 years). Multivariable Cox regression analysis was performed, including 64 preoperative, intraoperative, and postoperative factors separately in women and men.

RESULTS

There were no differences in in-hospital mortality (2.7% in men vs 2.9% in women, P = .639) and 5-year survival (82.0% +/- 0.8% in men vs 81.1% +/- 1.3% in women, P = .293). After adjustment for all independent predictors of long-term mortality, female sex was an independent predictor of improved 5-year survival (hazard ratio, 0.82; 95% confidence interval, 0.71-0.96; P = .014). Twenty-one independent predictors for long-term mortality were determined in men, whereas only 12 were determined in women. There were 9 common risk factors (age, ejection fraction, diabetes mellitus, > or =2 arterial grafts, postoperative myocardial infarction, deep sternal wound infection, sepsis and/or endocarditis, gastrointestinal complications, and respiratory failure); however, their weights were different between women and men. Malignant ventricular arrhythmias, calcified aorta, and preoperative renal failure were independent predictors only in women. Emergency operation, previous cardiac operation, peripheral vascular disease, left ventricular hypertrophy, current and past congestive heart failure, chronic obstructive pulmonary disease, body mass index of greater than 29, preoperative dialysis, thrombolysis within 7 days before coronary artery bypass grafting, intraoperative stroke, and postoperative renal failure were independent predictors only in men.

CONCLUSIONS

Despite equality between sexes in early outcome and superiority of female sex in long-term survival, there were 3 independent predictors for long-term mortality after coronary artery bypass grafting unique for women compared with 12 for men. Clinical decision making and follow-up should not be influenced by stereotypes but by specific findings.

Impact of Off-Pump Coronary Bypass Grafting on the Prevalence of Adverse Perioperative Outcome in Women Undergoing Coronary Artery Bypass Grafting Surgery

BACKGROUND

Female gender has been associated with a high prevalence of perioperative morbidity and mortality in coronary artery bypass grafting surgery (CABG). We attempted to determine a potential benefit of off-pump CABG as compared with on-pump CABG (OPCAB) with regard to perioperative outcome in female patients.

METHODS

Data were prospectively gathered on 2,182 consecutive female patients undergoing CABG either with or without cardiopulmonary bypass from 1996 to 2001. The associations between OPCAB surgery in addition with 22 further preoperative patient-related or treatment-related variables and 26 perioperative outcome variables were assessed with multivariable logistic regression analysis.

RESULTS

One hundred fifty-two (7.0%) female patients underwent OPCAB surgery during the study period. Women undergoing OPCAB had higher ejection fractions and received fewer coronary artery bypass grafts than CABG patients. Surgery using OPCAB was associated with shorter hospital stays, less bleeding, less transfusion requirements, and lower mortality than CABG. Furthermore, OPCAB surgery was independently associated with a lower prevalence of high perioperative transfusion requirement, postoperative respiratory insufficiency, postoperative renal insufficiency, and dialysis. Prevalence of postoperative blood loss of at least 500 mL was significantly higher after OPCAB surgery.

CONCLUSIONS

OPCAB in female patients undergoing coronary artery bypass surgery is safe and seems to be beneficial with regard to perioperative outcome as compared with conventional on-pump CABG. For that reason, off-pump surgery may be an effective method of lowering morbidity and mortality in these relatively high-risk patients.

On-Pump Versus Off-Pump Coronary Artery Bypass Surgery in a Matched Sample of Women

Background— Women have consistently higher mortality and morbidity than men after coronary artery bypass grafting (CABG). Whether elimination of cardiopulmonary bypass and performance of coronary artery bypass grafting off-pump (OPCAB) have a beneficial effect specifically in women has not been defined.

Methods and Results— From January 1998 through March 2002, 21 902 consecutive female patients at 82 hospitals underwent isolated CABG, as reported in an administrative database. Propensity score computer matching was performed based on 13 variables representing patient characteristics and preoperative risk factors to correct for and minimize selection bias. A total of 7376 (3688 pairs) women undergoing CABG surgery were able to be successfully matched. In a propensity score computer-matched cohort, multivariate logistic regression (odds ratio) revealed that women undergoing on-pump surgery had a 73.3% higher mortality ( P =0.002) and a 47.2% higher risk of bleeding complications ( P =0.019).

Conclusions— In a retrospective analysis of women undergoing CABG, computer-matched to minimize selection bias, off-pump surgery led to decreased mortality and morbidity including bleeding complications.

Gender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon

BACKGROUND

Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

OBJECTIVE

This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > or =65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.

METHODS

This was an ecological study based on a retrospective analysis of comparable administrative data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients. Differences in rates were examined by univariate analysis using the Student t test for statistical differences in mean values.

RESULTS

Despite differences in health system characteristics, including health insurance coverage, availability of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units. The rate of interventional treatment in women with CAD was less than half that in men. This difference persisted after adjustment for the prevalence of heart disease.

CONCLUSIONS

A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.

Time-related mortality for women after coronary artery bypass graft surgery: a population-based study

OBJECTIVE

This study explores the relative early and late mortality risks in women and men after coronary artery bypass graft surgery.

METHODS

This was a retrospective cohort study (n = 54,425 patients, 12,079 women) using clinical data for all patients who underwent isolated coronary artery bypass graft surgery in Ontario between fiscal years 1991 and 1999 obtained from the Cardiac Care Network database, with outcomes of early (< or =1 year) and late (>1 year up to 10 years) interval mortality identified through linkage to administrative databases.

RESULTS

Female surgical candidates were older (65 vs 62 years, P <.0001) and higher-risk patients. The risk-adjusted survival of female patients was worse than that of male patients in the first year after coronary artery bypass graft surgery, but their long-term mortality was similar to that of male patients. The Cox proportional hazards model for early mortality had an adjusted female hazard ratio of 1.44 (95% confidence interval, 1.29-1.61; P =.02). This significantly differed from the late mortality model, which had a hazard ratio of 0.89 (95% confidence interval, 0.78-1.0; P =.06).

CONCLUSIONS

Early mortality was significantly higher for women after coronary artery bypass graft surgery, despite adjustment for confounding factors. However, the long-term relative mortality risk for women appeared equivalent to or even better than that experienced by men as early as 1 year after coronary artery bypass graft surgery. This population-based study of long-term mortality supports the benefits of coronary artery bypass graft surgery for women in the current era. However, further research is needed to identify ways to reduce early postoperative mortality in women.

Operative results of coronary artery bypass grafting in women

BACKGROUND

The relative mortality of coronary artery bypass grafting (CABG) surgery in women is not certain. The purpose of this study was to examine the results of primary, isolated CABG in a series of Taiwanese female patients.

METHODS

Medical records of 2055 patients (188 women and 1867 men), who underwent primary, isolated CABG at Taipei Veterans General Hospital from January 1, 1991 to December 31, 1999, were reviewed. The mortality rate, associated with clinical and operative variables, was compared between female and male patients.

RESULTS

The female patients had more diabetes (51.6% vs. 29.9%, P<0.01), more hypertension (77.1% vs. 65.0%, P<0.01), and more hypercholesterolemia (39.4% vs. 29.6%, P<0.01), as compared with men. Fewer women consumed cigarette smoking (17.0% vs. 52.1%, P<0.001). Fewer internal mammary artery grafts were used in women (43.1% vs. 57.3%, P<0.001). Nine female (4.8%) and 93 male patients (5.0%) died. There was no significant difference in hospital mortality between women and men. Other variables, including age, angina class, NYHA class, incidence of peripheral arterial occlusive disease, stenosis of left main coronary artery, number of stenotic coronary arteries, incidence of emergent operations, anastomosis number, aortic cross-clamping time, cardiopulmonary bypass time, and left ventricular ejection fraction, were not significantly different between female and male patients.

CONCLUSIONS

Although the female patients were more frequently diabetic, hypertensive, and hypercholesterolemic, the hospital mortality of CABG in women was not significantly different from that in men. This result supports an aggressive surgical treatment for women with coronary artery disease.

Why are the results of coronary artery bypass grafting in women worse?

A study was conducted to assess the early results of isolated coronary artery bypass grafting in women and to determine the risk factors for early postoperative complications. Between January 1994 and July 2001, 1,730 patients (301 women and 1,429 men) underwent isolated myocardial revascularization. Conventional bypass procedure was performed on 1,554 patients (270 female and 1,284 male) and off-pump procedure on 176 patients (31 female and 145 male). Hospital mortality was significantly higher in women than in men (5.6% versus 2.9%). Low cardiac output syndrome developed in 8.6% of women and 8.5% of men. Postoperative myocardial infarction occurred in 5.3% of women and 4.3% of men (p < 0.05). The rate of infectious complications was significantly higher in women (7.0%) than in men (5.8%). The independent risk factors for early mortality in women were left ventricular ejection fraction below 40%, left main disease, and urgent operation. The need for urgent surgery in women was also found to be a significant independent predictor of low cardiac output syndrome and postoperative myocardial infarction. In conclusion, higher hospital mortality and morbidity in women undergoing coronary surgery are partially related to the severity of coronary atherosclerosis and comorbid conditions.

Gender differences in quality of distal vessels: effect on results of coronary artery bypass grafting

OBJECTIVE

The quality of target vessels may affect gender differences in outcome after coronary artery bypass grafting. This prospective study compares preoperative angiographic assessment of vessel quality with intraoperative visual assessment of size and presence or absence of diffuse disease. The effect of vessel quality on operative mortality and late survival is examined.

METHODS

Data were prospectively collected on 1939 consecutive patients undergoing isolated coronary artery bypass grafting by a single surgeon. Quality of target vessels was assessed preoperatively (angiogram) and intraoperatively by inspection and probe calibration.

RESULTS

Vessels were poorly visualized in 29% of female patients and 37% of male patients (P =.004), although all but 1.6% of target vessels were grafted. Women were no more likely than men to have small vessels (<1.5 mm) (57% vs 59%, P =.449) and were less likely to have distal disease (45% vs 53%, P =.005). Operative mortality was low, not statistically different in women versus men (1.3% vs 0.7%, P =.237), and increased in patients with distal disease (1.3% vs.03%, P =.021). Late survival was decreased in patients with poor left ventricle function, congestive heart failure, and peripheral vascular disease. Late survival was decreased in men with increased age, class IV symptoms, small size, and no left internal thoracic artery graft, and in women with recent myocardial infarction and preoperative cerebrovascular accident.

CONCLUSION

We conclude that in most patients with poorly visualized vessels in the preoperative angiogram, complete revascularization can be achieved if one is willing to graft small or diffusely diseased vessels. Women are no more likely than men to have vessels less than 1.5 mm in size and are less likely to have diffuse disease. Such an approach is associated with a low operative mortality and good long-term survival. Predictors of late survival were different for men and women. Neither small vessel size nor diffuse disease was an independent predictors of poor late outcome.

Gender profiling in coronary artery bypass grafting

OBJECTIVE

Although women are reported to be at increased risk of poor outcome after coronary artery bypass grafting, female gender may simply be a marker of a high-risk profile. Therefore, the objective of this study was to characterize the difference between the female and male profiles of patients presenting for coronary artery bypass grafting.

METHODS

From January 1993 to June 2002, 15,597 patients underwent isolated coronary artery bypass grafting at a single institution. Multivariable logistic regression was used to develop a model of female gender.

RESULTS

Of 15,597 patients, 3596 (23%) were women. Eighteen variables were predictive of the female gender profile, including shorter stature, increased weight, more hypertension, insulin-treated diabetes mellitus, heart failure, and higher triglyceride and high-density lipoprotein cholesterol levels. Hematocrit, bilirubin, and creatinine values were lower in women compared with men.

CONCLUSIONS

The preoperative profiles of women and men undergoing coronary artery bypass grafting are dissimilar. Statistical modeling techniques provide a unique perspective on the preoperative profile of the female patient, who is known to be at a higher risk undergoing coronary artery bypass grafting.

Gender and outcomes after coronary artery bypass grafting: a propensity-matched comparison

OBJECTIVE

Our objective is to determine whether gender is a marker or a causal influence for poor outcomes after coronary revascularization.

METHODS

Propensity-modeling techniques were used to investigate whether gender adversely impacts outcomes after coronary revascularization. A parsimonious explanatory model was developed by bootstrap bagging with variable selection from 64 baseline and 37 operative variables. Propensity scores were calculated from a logistic model that included the parsimonious model and additional baseline variables. Greedy matching techniques were applied to match female and male patients to the nearest propensity scores. Comparisons were made among the propensity-matched women and men.

RESULTS

Of the 15,597 patients undergoing isolated coronary artery bypass graft surgery, only 26% of the 3596 women were matched on propensity scores with men. Distribution of covariates among the matched pairs was, on average, equal. Postoperative mortality (P =.76), neurologic morbidity (global deficit P =.07, focal deficit P =.51), infection (sepsis P =.88), mediastinitis (P =.18), renal failure (P =.84), intra-aortic balloon pump usage (P =.61), and reoperation for bleeding (P =.10) were similar among women and men. Occurrence of Q-wave myocardial infarction (P = <.01), postoperative inotropic usage (P = <.01), and prolonged ventilatory support (P =.02) were more common in women compared with propensity-matched men.

CONCLUSIONS

The preoperative profiles of women and men are markedly different. Propensity matching women and men was difficult, because only 26% of women were able to be matched with men. However, in well-matched patients, female gender was not associated with increased mortality and had minimal impact on morbidity after coronary artery bypass grafting.

Mild to moderate mitral regurgitation in patients undergoing coronary bypass grafting: effects on operative mortality and long-term significance

BACKGROUND

Patients undergoing bypass grafting (CABG) often present with mitral regurgitation (MR). While surgical strategy for patients with either trace or severe MR is well established, the need for a valve procedure with mild (2) to moderate (3+) mitral regurgitation is controversial.

METHODS

We reviewed 1,939 consecutive CABG patients (1987 to 1999). A preoperative echocardiogram performed when clinically indicated graded MR from 1 to 4+. Patient characteristics, hospital mortality, and long-term survival were compared between 167 patients with grade 2 to 3+ MR and controls. A multivariate analysis identified independent predictors for long-term mortality.

RESULTS

The MR patients were more often female and older; had increased comorbidities including hypertension, diabetes, and heart failure; had more extensive coronary disease and worse left ventricular (LV) function; and required urgent surgery more often. Operative mortality was 0.8% in no MR patients and 1.8% in MR patients (p not significant). Long-term survival for MR patients with poor LV function (LV grade 3 to 4) was significantly lower (53% versus 75% at 10 years, p = 0.001). Independent predictors of poor long-term survival were advanced age, LV dysfunction, heart failure, diabetes, prior cerebrovascular accident, peripheral vascular disease, and no left internal mammary artery use.

CONCLUSIONS

Coronary artery bypass graft patients with mild or moderate MR have worse baseline characteristics but operative mortality with CABG alone is not significantly increased. Long-term prognosis for MR patients with poor LV function is worse compared with patients with no MR but MR was not an independent predictor of long-term mortality. To determine whether surgical correction of MR would improve results, a prospective randomized trial seems warranted.

Gender and cardiac surgery

The increased operative mortality and morbidity of women compared with men undergoing CABG surgery results from multiple differences in presentation, preoperative risk profile, and surgical factors. Investigators have found consistently that women present with a different preoperative risk profile than do men. Women more commonly have factors associated with increased short- and long-term mortality, such as less frequent use of IMA grafts. Differences in study design and patient population may contribute to variability in short- and long-term mortality among the various studies. The lack of representation of women in older clinical trials has hindered our understanding of the management of CAD in women; this situation must be remedied in future studies, [95]. Known physiologic and anatomic differences must be evaluated for their effects on outcomes. Further studies are needed to evaluate gender-related differences in autonomic responses to acute coronary occlusion, complications related to cardiopulmonary bypass, susceptibility to abnormalities in coagulation, and other factors that might account for discrepant outcomes in men versus women undergoing CABG [96]. Beyond these factors, specific pharmacologic and therapeutic considerations, such as the role of estrogen replacement therapy, need to be clarified. As further knowledge accumulates, it is hoped that gender-specific risk factors can be mitigated and protective factors exploited, thereby improving the outcomes for all cardiac surgery patients.

Gender-related differences in morbidity and mortality during combined valve and coronary surgery

BACKGROUND

Gender-related differences in morbidity and mortality are well described for coronary artery bypass grafting but are not well understood for combined valve and bypass surgery.

METHODS

We reviewed retrospectively the morbidity and mortality of 1570 consecutive patients who underwent combined valve and bypass procedures at the Toronto General Hospital between January 1990 and October 2000.

RESULTS

There were 1073 men (68%) and 497 women (32%). The mean ages (+/- 1 SD) of women and men were 69 +/- 9 and 68 +/- 9 years, respectively (P =.02). Of the 1570 total patients, 973 patients (62%) underwent aortic valve and coronary bypass surgery, 481 patients (31%) had mitral valve and coronary bypass operations, and 116 (7%) patients had double or triple valve and coronary bypass operations. Preoperative hypertension (P =.002), diabetes (P =.001), and atrial fibrillation (P =.001) were seen more frequently in women. Body surface area was significantly lower in women (P =.0001). At presentation, more women were in congestive heart failure (69% vs 58%, P =.001) and in New York Heart Association functional class III or IV (25% vs 19%, P =.001). Although there was no difference in the number of women with three or more diseased vessels (32% vs 38%), only 35% of women received three or more grafts compared with 44% of men (P =.001). The use of left internal thoracic grafts, although uncommon in the whole study population (36%), was less common in women than in men (26% vs 41%, P =.001). Multivariable logistic analyses for morbidity and mortality showed female gender to be an independent risk factor. Mitral valve replacement, age, left ventricular dysfunction, New York Heart Association classes III and IV, and association of tricuspid valve disease, diabetes, peripheral vascular disease, and preoperative renal failure were found to be independent risk factors for mortality.

CONCLUSION

Female gender is an independent risk factor for combined morbidity and mortality during and after combined valve and coronary bypass surgery. As with isolated coronary artery bypass grafting, women undergoing combined procedures have more premorbid conditions, are more often in heart failure, had an equal incidence of triple vessel disease but received fewer grafts than men, and, therefore, were more frequently incompletely revascularized.

Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report

BACKGROUND

The purpose of this study was to evaluate whether women undergoing cardiac surgery are more likely to suffer neurological complications than men and whether these complications could explain, at least in part, their higher perioperative mortality.

METHODS AND RESULTS

The Society of Thoracic Surgery National Cardiac Surgery Database was examined for the years 1996 and 1997 to determine the frequency of new neurological events (stroke, transient ischemic attack, or coma) occurring after cardiac surgery. We reviewed clinical information on 416 347 patients (32% women) for whom complete neurological outcome data were available. New neurological events after surgery were higher for women than for men (3.8% versus 2.4%, P=0.001). For the whole group, the 30-day mortality was higher for women than for men (5.7% versus 3.5%, P=0.001), and among those patients who suffered a perioperative neurological event, mortality was also significantly higher for women than men (32% versus 28%, P=0.001). After adjustment for other risk factors (eg, age, history of hypertension and/or diabetes, duration of cardiopulmonary bypass, and other comorbid conditions) by multivariable logistic regression, female sex was independently associated with significantly higher risk of suffering new neurological events after cardiac surgery (OR 1.21, 95% CI 1.14 to 1.28, P=0.001).

CONCLUSIONS

Women undergoing cardiac surgery are more likely than men to suffer new perioperative neurological events, and they have higher 30-day mortality when these complications occur. The higher incidence of perioperative neurological complications in women cannot be explained by currently known risk factors.

Sternal Wound Infection Prediction Scale: a test of the reliability and validity

The purpose of the present study was to determine the reliability and validity of the Sternal Wound Infection Prediction Scale. The tool was developed to fill the need for a quick and easy way to determine which patients are at risk of developing a sternal wound infection in order that preventive measures can be instituted. Data were collected by a retrospective chart review of 56 patient records, 27 who developed a sternal wound infection and 29 who did not. In this group of patients, obesity and diabetes were found to be statistically significant risk factors. Pharmacological support was found to be a clinically significant factor. Of the infected group, 68.4% of patients who developed a sternal wound infection were predicted to do so by the tool.

Improved in-hospital mortality in women undergoing coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group

BACKGROUND

Few studies have examined the changes in in-hospital mortality for women over time. We describe the changing case mix and mortality for women undergoing coronary artery bypass grafting (CABG) from 1987 to 1997 in northern New England.

METHODS

Data were collected on 8,029 women and 21,139 men undergoing isolated CABG. The study consisted of three time periods (1987 to 1989, 1990 to 1992, and 1993 to 1997) to account for regional efforts to improve quality of care that occurred during 1990 to 1992.

RESULTS

Compared with 1987 to 1989, women undergoing CABG in 1993 to 1997 were older, had poorer ventricular function, and more often required urgent or emergency operations. The crude and adjusted mortality rates for both women and men decreased significantly over time. The absolute magnitude of the change in adjusted rates was greater for women (3.1%) than for men (1.5%). Although women represented only 28% of the study population, the decrease in their mortality accounted for 44% of the total decrease in adjusted mortality during the study period.

CONCLUSIONS

Over the last decade there has been a marked decrease in CABG mortality for women, despite a worsening case mix.

Age and sex differences in the distribution and ultrasound morphology of carotid atherosclerosis: the Tromsø Study

Atherosclerosis begins early in life and is the major underlying cause of cardiovascular morbidity and death. Yet, population-based information on age and sex differences in the extent and morphology of atherosclerosis throughout life is scarce. Carotid atherosclerosis can be visualized with B-mode ultrasound and is a marker of atherosclerosis elsewhere in the circulation. We assessed both the prevalence and the morphology of carotid atherosclerosis by B-mode ultrasound in 3016 men and 3404 women, 25 to 84 years old, who participated in a population health survey. The participation rate was 88%. Plaque morphology was graded according to whether a plaque was predominantly soft (echolucent) or hard (echogenic). Atherosclerotic plaques were found in 55.4% of the men and 45.8% of the women. In men, there was a linear increase with age in the prevalence of carotid atherosclerosis, whereas in women, there was a curvilinear age trend, with an inflection in the prevalence rate of women at approximately 50 years of age. The male predominance in atherosclerosis declined after the age of 50 years, the plaque prevalence being similar in elderly men and women. Men had softer plaques than women; this sex difference in plaque morphology increased significantly (P=0.005) with age. The sex difference in the prevalence of atherosclerosis and the female age trend in atherosclerosis show significant changes at the age of approximately 50 years, suggesting an adverse effect of menopause on atherosclerosis. The higher proportion of soft plaques in men compared with women increases with age and may partly account for the prevailing male excess risk of coronary heart disease in the elderly despite a similar prevalence of atherosclerosis in elderly men and women.

Impact of body mass index and albumin on morbidity and mortality after cardiac surgery

OBJECTIVE

Extremely thin and overly obese patients may not tolerate cardiac surgery as well as other patients. A retrospective study was conducted to determine whether the extremes of body mass index (weight/height(2) [kg/m(2)]) and/or cachexia increased the morbidity and mortality associated with cardiac operations.

METHODS

Body mass index was used to objectively measure "thinness" (body mass index < 20) and "heaviness" (body mass index > 30); preoperative serum albumin was used to quantify nutritional status and underlying disease. Data were gathered between 1993 and 1997 from 5168 consecutive patients undergoing coronary artery bypass or valve operations, or both.

RESULTS

No significant correlations were observed between body mass index and preoperative albumin levels. Low body mass index (<20) and low albumin level (<2.5 g/dL) were each independently associated with increased mortality after cardiopulmonary bypass (P </=.0005). Operative mortality was highest among those with both low body mass index and low albumin level. Multivariable logistic regression, adjusting for potentially confounding variables, demonstrated that an albumin level of less than 2.5 g/dL was independently associated with increased risk of reoperation for bleeding, postoperative renal failure, and prolonged ventilatory support, intensive care unit stay, and total length of stay. A body mass index of more than 30 was associated with increased sternal wound infection and saphenous vein harvest site infection.

CONCLUSIONS

Hypoalbuminemia and low body mass index each independently predict increased morbidity and mortality after cardiac operations. Preoperative risk stratification with the use of body mass index and serum albumin may help to identify subgroups of patients at high risk for adverse outcomes after cardiac operations.

Gender differences in accessing cardiac surgery across England: a cross-sectional analysis of the health survey for England

OBJECTIVE

To examine gender differences in access to cardiac surgery in a nationally representative sample.

DESIGN

Nationwide cross sectional household based survey (Health Survey for England).

SETTING

Private households in England around 1993 and 1994.

SUBJECTS

1708 subjects reporting a history of either doctor diagnosed angina or heart attack from a stratified random sample of 32 378 people aged 16 and above.

OUTCOME MEASURE

The proportion reporting having had cardiac surgery or on a waiting list.

RESULTS

13.5% reported previous (n = 206) or pending (n = 25) cardiac surgery. Men were more likely than women to have had or to be waiting for cardiac surgery (19.1% of men versus 6.8% of women, chi2 54.7, P<0.001). This finding was consistent regardless of age group and across three regional areas. The unadjusted odds ratio for cardiac surgery for men versus women was 3.3 (95% Cl 2.3, 4.5, P<0.001) and was only slightly attenuated to 2.8 (95% CI 1.9, 4.0. P<0.001), after adjustment for other factors. The gender difference remained even when analysis was restricted to subjects reporting a previous heart attack, and after statistical adjustment for disease severity.

CONCLUSION

Women are less likely than men to receive cardiac surgery across all age groups and regional areas. These results include private operations and adjust for individual behavioural data. Neither disease severity or co-morbidity explains these discrepancies. Further studies are required to determine why this inequality occurs and how it can be addressed.

Impact of gender on coronary bypass operative mortality

BACKGROUND

In spite of many reports investigating the influence of gender on coronary artery operations, it is still uncertain whether gender is an independent risk factor for operative mortality. A major problem of previous reports has centered around the fact that men and women constitute quite different populations, thereby making direct comparisons difficult.

METHODS

The Society of Thoracic Surgeons National Cardiac Surgery Database was used to retrospectively examine 344,913 patients undergoing coronary artery bypass graft operations from 1994 through the most recent data harvest. The operative mortality of male and female patients was compared for a variety of single risk factors and combinations of risk factors. A logistic risk model was used to account for all important patient parameters so that individuals could be stratified into comparable categories allowing for direct comparisons of risk-matched male and female patients.

RESULTS

The univariate analysis showed that the 97,153 women carried a significantly higher mortality for each of the risk factors examined. The multivariate analysis and the risk model stratification showed that women had significantly higher mortality as compared to equally matched men in the low- and medium-risk part of the spectrum, but in high-risk patients, there was no difference between male and female mortality.

CONCLUSIONS

Gender is an independent predictor of operative mortality except for patients in very high-risk categories.

Risk factors for stroke in patients undergoing coronary artery bypass grafting

OBJECTIVE

To determine predictors of stroke in patients undergoing first-time coronary bypass grafting, we prospectively collected data on 1631 consecutive patients.

METHODS

Patients with a history of stroke and/or central nervous system symptoms (n = 134) and/or carotid bruits (n = 95) underwent carotid Doppler evaluation. Stenosis greater than 70% was considered significant. Patients with symptomatic disease or asymptomatic bilateral disease were referred for combined coronary bypass and carotid endarterectomy (n = 21). Patients with neurologic symptoms after the operation were assessed by a neurologist and underwent a computed tomographic scan. Events were classified as reversible transient ischemic attack, reversible ischemic neurologic deficit, or irreversible stroke.

RESULTS

There were 19 strokes (1.2%) and 20 deaths (1.2%) in this series. In patients with carotid screening, risk of stroke increased with severity of carotid disease and ranged from 0% in patients without stenosis, to 3.2% (1/31) in those with greater than 70% stenosis, and to 27.3% (6/22) in those with carotid occlusion. By stepwise logistic regression analysis six variables were identified as risk factors for stroke. The most important predictor was carotid occlusion with or without contralateral stenosis (odds ratio = 28, 95% confidence interval (8,105). In this group, four of five strokes occurred on the occluded side. Other risk factors were presence of ascending aortic disease at the time of surgery (odds ratio = 12.8, confidence interval 3,48), perioperative myocardial infarction (odds ratio = 8.2, confidence interval 2,33), poor left ventricular function (odds ratio = 4.6, confidence interval 1,19), peripheral vascular disease (odds ratio = 3.2, confidence interval 1,9), and age > 60 years (odds ratio = 2.9, confidence interval 0.8,11).

CONCLUSION

We conclude that risk factors for perioperative stroke in patients undergoing coronary artery bypass grafting are multiple. Carotid scanning in patients with neurologic symptoms or carotid bruits can identify patients at increased risk. Patients with carotid occlusion are at high risk for stroke on the occluded side.