Coronary Artery Surgery in Women

This year, the National Heart, Lung, and Blood Institute (NHLBI) launched “The Heart Truth” campaign, and the American Heart Association (AHA) launched the “Go Red for Women” campaign to combat lack of awareness that cardiovascular disease is the number one killer of women (just as it is for men) and kills 8 times as many women as does breast cancer. The AHA Heart Disease and Stroke Statistics 2004 Update notes that 516,000 American patients undergo coronary artery bypass grafting (CABG) procedures each year and that over 150,000 of these are women. There is considerable ongoing debate about whether women's higher risk of morbidity and mortality after CABG surgery is due to female sex per se or to the tendency for women to be diagnosed with heart disease at a later stage, when they have a greater number of unfavorable risk factors. This debate has recently generated much original research and numerous editorials, in journals such as Circulation, the Journal of the American College of Cardiology, the Journal of Thoracic and Cardiovascular Surgery, and the Annals of Thoracic Surgery.

Yet, long before the current surge of interest, in the earliest years of CABG surgery, Bolooki and colleagues published a case series on the subject of coronary artery surgery in women, which appeared in a 1974 issue of Cardiovascular Diseases, Bulletin of the Texas Heart Institute (now the Texas Heart Institute Journal). This article was perhaps the first—and no doubt among the first—to specifically discuss the threat to women's health represented by cardiovascular disease. The authors articulate their impression that “our female patients were not profiting from this operation to an extent comparable to the male population.” Specifically, the women in the study suffered a slightly increased operative mortality rate and a 2-fold increase in the incidence of perioperative myocardial infarction. Furthermore, there was a higher incidence of graft closure and residual symptomatic angina in the women, compared to the men. The authors speculate that the coronary arterial anastomoses were technically more difficult to perform in women. Other prescient observations in their manuscript include a description of postoperative diastolic dysfunction in women, despite better preoperative cardiac function than that in men. This article is reproduced in this issue, exactly as it was published in 1974.

The higher morbidity and mortality rates in female CABG patients, little changed after 30 years, emphasize the need for further research. Potentially fertile areas of study include the development of a better understanding of the profile of women at highest risk for CAD, sex-specific advantages and disadvantages of various coronary revascularization techniques (including off-pump CABG surgery and percutaneous transluminal coronary angioplasty), transfusion-related outcomes, endocrine and inflammatory responses in women undergoing CABG, and the pharmaceutical and surgical options for heart failure in women. The hope is to be able to mitigate sex-specific risk factors and exploit any sex-specific protective factors, in order to improve outcomes in all patients.