Download Women are more likely to have low cardiac output

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.