Sex differences in mortality after first time, isolated coronary artery bypass graft surgery: a systematic review and
Stacey Matthews1,2,3, Amanda Buttery1, Adrienne O'Neil2,4
1National Heart Foundation of Australia, Melbourne, VIC, Australia.
Insights
Mortality after coronary artery bypass graft surgery (CABGS) shows inconsistent sex-specific differences. Further trials with sex-specific data are needed for tailored revascularization treatments.
Area of Science:
- Cardiovascular Surgery
- Clinical Trials
- Sex-Specific Medicine
Background:
- Contradictory reports exist regarding sex-specific mortality differences following coronary artery bypass graft surgery (CABGS).
- This review aimed to compare the efficacy of CABGS versus alternative revascularization procedures concerning sex-specific short- and longer-term mortality.
- Understanding these differences is crucial for optimizing patient care and treatment strategies.
Approach:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) published since 2010 were conducted.
- Studies compared isolated CABGS to alternative revascularization methods, including English language publications.
- Data were analyzed using Mantel-Haenszel fixed-effects modeling, with risk of bias and quality assessments performed.
Key Points:
- Pooled analyses showed similar overall mortality risk for women compared to men (RR 0.94, 95% CI 0.84-1.05).
- However, sensitivity analyses excluding high-risk patients indicated a higher mortality risk for women (RR 1.22, 95% CI 1.01-1.48).
- Women experienced a mortality risk reduction at 30 days (18%) and 10 years (19%), but an increased risk at 2-5 years (25%) compared to men.
Conclusions:
- Meta-analysis indicates inconsistent sex-specific mortality differences after CABGS.
- Women were under-represented in the pooled population, decreasing from 41% at 30 days to 16.7% at 10 years.
- Future trials must incorporate sex-specific stratification to develop appropriate, sex-differentiated revascularization treatments.
Aim:
Reports of sex-specific differences in mortality after coronary artery bypass graft surgery (CABGS) are contradictory. The review aim was to determine whether CABGS is differentially efficacious than alternative procedures by sex, on short- and longer-term mortality.
Methods And Results:
EMBASE, CINAHL, Medline, and the Cochrane Library were searched. Inclusion criteria: English language, randomized controlled trials from 2010, comparing isolated CABGS to alternative revascularization. Analyses were included Mantel-Haenszel fixed-effects modelling, risk of bias (Cochrane RoB2), and quality assessment (CONSORT). PROSPERO Registration ID: CRD42020181673. The search yielded 4459 citations, and full-text review of 29 articles revealed nine studies for inclusion with variable time to follow-up. Risk of mortality for women was similar in pooled analyses [risk ratio (RR) 0.94, 95% confidence interval (CI) 0.84-1.05, P = 0.26] but higher in sensitivity analyses excluding 'high risk' patients (RR 1.22, 95% CI 1.01-1.48, P = 0.04). At 30 days and 10 years, in contrast to men, women had an 18% (RR 0.82, 95% CI 0.66-1.02, P = 0.08) and 19% (RR 0.81, 95% CI 0.69-0.95, P = 0.01) mortality risk reduction. At 1-2 years women had a 7% (RR 1.07, 95% CI 0.69-1.64, P = 0.77), and at 2-5 years a 25% increase in risk of mortality compared with men (RR 1.25, 95% CI 1.03-1.53, P = 0.03). Women were increasingly under-represented over time comprising 41% (30 days) to 16.7% (10 years) of the pooled population.
Conclusion:
Meta-analysis revealed inconsistent sex-specific differences in mortality after CABGS. Trials with sex-specific stratification are required to ensure appropriate sex-differentiated treatments for revascularization.
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