Coronary artery bypass grafting in women: optimizing operative outcomes

Women undergoing coronary artery bypass grafting (CABG) continue to experience worse perioperative and long-term outcomes than men despite advances in surgical techniques and perioperative care. This review summarizes contemporary evidence on sex-related differences in coronary artery disease (CAD), surgical outcomes, and secondary prevention. Gaps in the current evidence are identified and priorities for optimizing outcomes and informing sex-specific clinical practice are highlighted.

Women present with distinct patterns of CAD, including higher prevalence of microvascular dysfunction and nonobstructive disease, contributing to delayed diagnosis and referral for surgical revascularization. Women are less likely to receive guideline-recommended revascularization strategies, including multiple arterial grafting. Women also experience higher rates of graft failure, mortality, and stroke after CABG. Emerging observational evidence suggests that off-pump and minimally invasive CABG approaches may reduce the disparities in female patients, although randomized sex-specific data remains limited. Secondary prevention remains suboptimal, with persistent gaps in implementation of guideline-directed therapies.

Significant disparities persist across the continuum of care for women undergoing CABG, from diagnosis through long-term secondary prevention. Improving equitable implementation of evidence-based surgical strategies, increasing representation of women in randomized clinical trials, and developing sex-specific evidence are essential to optimize outcomes and inform future clinical guidelines.