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Special Considerations for Women Undergoing CABG by Jennifer L. Ellis, MD MBA Women are under represented in clinical trials. 9% 1970 41% 2006 % of total pop with disease % of studied pop Hypertension 53 44 Diabetes 50 40 Heart Failure 51 29 Hyperlipidemia 49 28 Coronary Artery Disease 46 25 Sex specific results were discussed in only 31% of the primary trial publications Representation of Women in Randomized Clinical Trials of Cardiovascular Disease Prevention. Circ Cardiovasc Qual Outcomes. 2010 Feb 16. [Epub ahead of print] Melloni, C., Berger J.S., et al Women who have Coronary Artery Bypass Grafting are older, sicker, poorer less educated and less socially engaged than their male counterparts. Comparison of Health-Related Quality-of-Life Outcomes of Men and Women After Coronary Artery Bypass Surgery Through 1 Year: Findings From The POST CABG Biobehavioral Study Ruth Lindquist, PhD; Gilles Dupuis, PhD; et al for the POST CABG Biobehavioral Study Investigators American Heart Journal. 2003;146(6):1038-1044. Women are 1.6 times more likely to have operative mortality than men even when correcting for preoperative risk factors. Operative mortality in women and men undergoing coronary artery bypass grafting (from the California Coronary Artery Bypass Grafting Outcomes Reporting Program) Bukkapatnam, RN, Yeo KK et al Am J Cardiol. 2010 Feb 1;105(3):339-42. Epub 2009 Dec 21 Women have a greater risk of infection pulmonary dysfunction and death after heart surgery. Women are more likely to receive transfusions and a greater quantity of transfusions than men. Those who received blood are more than 4 times more likely to develop an infection. There is a correlation between transfusion and fever with length of stay. A possible cause for the increase in mortality in women after CABG may be related to blood transfusions. Increased risk of infection and mortality in women after cardiac surgery related to allogeneic blood transfusion Rogers, MA, Blumberg, etal J Womens Health (Larchmt). 2007 Dec;16(10):1412-20. Women are more likely to have low cardiac output syndrome than men. The mortality of low cardiac output syndrome was 16.9% v .9% in those who did not developed low cardiac output syndrome. Predictors of low cardiac output syndrome after coronary artery bypass Rao, V, Ivanov, J et al J Thorac Cardiovasc Surg. 1996 Jul;112(1):38-51 OPCAB decreased some of the increased risk of surgery women have compared to on pump bypass surgery. Off-Pump Techniques Disproportionately Benefit Women and Narrow the Gender Disparity in Outcomes After Coronary Artery Bypass Surgery Puskas, JD, Kilgo, PD et al. Circulation. 2007;116:I-192 – I-199.) Survival at 3, 5, and 10 years lags for blacks compared to whites and this disparity is not lessened by OPCAB techniques. Racial Disparity Persists After On-Pump and Off-Pump Coronary Artery Bypass Grafting Cooper, WA, Thourani, VH Circulation. 2009;120:S59-S64 Short term survival benefits of OPCAB did not persist in long term follow up, and women with OPCAB have a higher adjusted risk for major cardiac and cerebral effects after OPCAB Impact of Off-Pump Techniques on Sex Differences in Early and Late Outcomes After Isolated Coronary Artery Bypass Grafts Shao-peng Fu, MD*, Zhe Zheng, MD*, Chinese Academy of Medical Science, Peking Union Medical College, Fuwai Hospital & Cardiovascular Institute, Department of Surgery, Research Center for Cardiovascular Regenerative Medicine, Beijing, People's Republic of China Ann Thorac Surg 2009;87:1090-1096 Although early mortality was significantly higher for women, long term relative mortality risk appears equivalent, or even better than men as early as 1 year after bypass. Time-related mortality for women after coronary artery bypass graft surgery: a population-based study. Guru V, Fremes SE, et al J Thorac Cardiovasc Surg. 2004 Apr;127(4):1158-1165. The Bari trial states that since women do as well long term as men with higher risk profiles, female sex is an independent predictor of improved 5 year survival. Better outcome for women compared with men undergoing coronary revascularization: A report from the Bypass Angioplasty Revascularization Investigation (BARI). Jacobs AK, Kelsey SF, et al Circulation 1998;98:1279-1285 Summary of CABG in the real world Six large databases (80,000 patients) show survival benefit for CABG over PCI Consistent survival benefit of 5% in absolute terms at 3-5 years (or decrease in risk of death of 3040%) Underestimates the real survival benefit of CABG because of increasing crossovers from the PCI group to CABG (around 10% by 3 years) Reduces by up to seven fold the need for further intervention within 3 years DP Taggart MD PhD FRCS Professor of Cardiovascular Surgery University of Oxford STS/AATS Tech-Con Jan 2007 Guru V, Fremes SE, Tu JV. Time-related mortality for women after coronary artery bypass graft surgery: a population-based study. J Thorac Cardiovasc Surg. 2004 Apr;127(4):1158-1165. J. Herlitz, G. Brandrup-Wognsen, B. W. Karlson, H. Sjöland, T. Karlsson, K. Caidahl, M. Hartford & M. Haglid. Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women. Journal of Internal Medicine. 2000;247(4):500-506. Jacobs AK, Kelsey SF, Brooks MM, Faxon DP, Bernard R. Chaitman BR, Bittner V, Mock MB, Weiner BH, Dean L, Winston C, Drew L, Sopko G. Better outcome for women compared with men undergoing coronary revascularization: A report from the Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1998;98:1279-1285. Mickleborough, LL, Takagi Y, Mariyama H, Sun Z, Mohamed S. Is sex a factor in determining operative risk for aortocoronary bypass surgery? Circulation. 1995;92(suppl I):II80- II84 Herlitz J, Brandrup-Wognsen G, Karlson BW, Sjoland H, Karlsson T, Caidahl K et al. Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women. J Intern Med. 2000;247:500–506. Petro KR, Dullum MK, Garcia JM, Pfister AJ, Qazi AG, Boyce SW, Bafi AS, Stamou SC, Corso PJ. Minimally invasive coronary revascularization in women: A safe approach for a high-risk group. Heart Surg Forum. 2000;3(1):4146. Between 1990 and 2003, 2255 patients underwent isolated AV surgery with no other concomitant cardiac surgery. The independent predictors of LCOS and operative mortality (OM) were determined by stepwise logistic regression analysis. The overall prevalence of LCOS was 3.9%. The independent predictors of LCOS were (odds ratio in parentheses) renal failure (5.0), earlier year of operation (4.4), left ventricular ejection fraction <40% (3.6), shock (3.2), female gender (2.8), and increasing age (1.02). Overall OM was 2.9%. The OM was higher in patients who experienced LCOS (38% versus 1.5%; P<0.001). The independent predictors of mortality were (odds ratio in parentheses) preoperative renal failure (8.3), urgency of surgery (3.4), previous stroke (2.9), congestive heart failure (2.6), previous cardiac surgery (2.3), hypertension (1.7), and small AV size (1.3). CONCLUSIONS: Low-output syndrome is associated with significantly increased morbidity and mortality Circulation. 2005 Aug 30;112(9 Suppl):I448-52. Predictors of low cardiac output syndrome after isolated aortic valve surgery. Maganti MD, Rao V, Borger MA, Ivanov J, David TE. April 2004 and December 2008. Predictors of mortality and major adverse cardio and cerebrovascular events (MACCEs) on the postoperative and follow-up period were determined through multivariable analysis. Four hundred and fifty-one patients were included in the study. Ninety-four (20.8%) were >/=80. Previous cardiac surgery [odds ratio (OR)=4.08, P=0.047], renal failure (OR=6.75, P<0.001), concomitant coronary artery bypass grafting (CABG) (OR=2.57, P=0.034), female sex (OR=2.49, P=0.047), and severe pulmonary hypertension (OR=3.68, P=0.024) were independent predictors of inhospital mortality. In the follow-up, age >/=80 years [Hazard ratio (HR)=2.44, P=0.02], high blood pressure (HBP) (HR=5.2, P=0.025) and peripheral arterial disease (PAD) (HR=s5.1, P<0.001) were independent predictors for late mortality. Only PAD (HR=3.55, P=0.014) and HBP (HR=8.24, P=0.04) were independent predictors for late cardiac mortality. Renal failure (OR=2.57, P=0.005), severe pulmonary hypertension (OR=3.49, P=0.005) and concomitant CABG (OR=2.49, P=0.002) were independent predictors for postoperative MACCEs. Diabetes mellitus (HR=2.03, P=0.033 and PAD (HR=2.3, P=0.041) were independent predictors for MACCEs in the follow-up Interact Cardiovasc Thorac Surg. 2010 Jan 25. [Epub ahead of print] Short- and mid-term results for aortic valve replacement in octogenarians. Carnero-Alcazar M, Reguillo-Lacruz F, Alswies A, Villagran-Medinilla E, Maroto-Castellanos LC, RodriguezHernandez JE. Intern Med J. 2010 Jan 4. [Epub ahead of print] CARDIOVASCULAR RISK MODIFICATION IN PARTICIPANTS WITH CORONARY DISEASE SCREENED BY THE KIDNEY EARLY EVALUATION PROGRAM. McCullough PA, Whaley-Connell A, Brown WW, Collins AJ, Chen SC, Li S, Norris KC, Jurkovitz C, McFarlane S, Obialo C, Sowers J, Stevens L, Vassalotti JA, Bakris GL; on Behalf of the KEEP Investigators. Department of Medicine, Divisions of Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital, Royal Oak, MI. Abstract Background. Coronary artery disease (CAD) identifies the need for intensive treatment of risk factors among individuals with chronic kidney disease (CKD), a high-risk, complex cardiovascular risk state. Methods. An estimated glomerular filtration rate <60 ml/min/1.73 m2 or a urine albumin:creatinine ratio (ACR) >/=30 mg/g (3.4 mg/mmol) defined CKD. Results. Of 70,454 volunteers screened the mean age was 53.5 +/- 15.7 years and 68.3% were female. A total of 5,410 (7.7%) had a self-reported history of CAD; 1,295 (1.8%) had a history of prior percutaneous coronary intervention (PCI); and 1,124 (1.6%) had a prior history of coronary artery bypass surgery (CABG). Multivariate analysis for the outcome of suboptimal CAD risk management (composite of systolic blood pressure >/= 130 mmHg, glucose >/= 125 mg/dl (6.9 mmol/L) for diabetics, total cholesterol >/=200 mg/dl (5.2 mmol/L), or current smoking; n = 38746/53403, 72.5%), revealed older age (per year) OR = 1.04, 95% CI 1.03-1.04, p < 0.0001; male gender OR = 1.40, 95% CI 1.34-1.47, p < 0.0001; ACR >/= 30 mg/g (3.4 mg/mmol) OR = 1.66, 95% CI 1.55-1.79, p < 0.0001; body mass index (per kg/m2) OR = 1.06, 95% CI 1.06-1.06, p < 0.0001; CAD without a history of revascularization OR = 1.14, 95% CI 1.02-1.28, p = 0.02; and care received by a nephrologist OR = 1.49, 95% CI 1.22-1.83, p < 0.0001; were associated with worse risk factor control. Prior coronary revascularization and being under the care of a cardiologist were not associated with either improved or suboptimal risk factor control. Conclusions. Chronic kidney disease is associated with overall poor rates of CAD risk factor control.