Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA.
Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, 40 Duke Medicine Cir, Durham, NC 27710, USA.
Eur Heart J. 2021 Dec 28;43(1):18-28. doi: 10.1093/eurheartj/ehab504.
Data suggest that women have worse outcomes than men after coronary artery bypass grafting (CABG), but results have been inconsistent across studies. Due to the large differences in baseline characteristics between sexes, suboptimal risk adjustment due to low-quality data may be the reason for the observed differences. To overcome this limitation, we undertook a systematic review and pooled analysis of high-quality individual patient data from large CABG trials to compare the adjusted outcomes of women and men.
The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE). The secondary outcome was all-cause mortality. Multivariable mixed-effect Cox regression was used. Four trials involving 13 193 patients (10 479 males; 2714 females) were included. Over 5 years of follow-up, women had a significantly higher risk of MACCE [adjusted hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.21; P = 0.004] but similar mortality (adjusted HR 1.03, 95% CI 0.94-1.14; P = 0.51) compared to men. Women had higher incidence of MI (adjusted HR 1.30, 95% CI 1.11-1.52) and repeat revascularization (adjusted HR 1.22, 95% CI 1.04-1.43) but not stroke (adjusted HR 1.17, 95% CI 0.90-1.52). The difference in MACCE between sexes was not significant in patients 75 years and older. The use of off-pump surgery and multiple arterial grafting did not modify the difference between sexes.
Women have worse outcomes than men in the first 5 years after CABG. This difference is not significant in patients aged over 75 years and is not affected by the surgical technique.
数据表明,女性在冠状动脉旁路移植术(CABG)后的结局比男性差,但研究结果不一致。由于性别间基线特征存在较大差异,由于数据质量低导致的风险调整不充分可能是观察到差异的原因。为了克服这一局限性,我们对来自大型 CABG 试验的高质量个体患者数据进行了系统评价和汇总分析,以比较女性和男性的调整结局。
主要结局是全因死亡率、心肌梗死(MI)、卒中和再次血运重建(主要心脏和脑血管不良事件,MACCE)的复合结局。次要结局是全因死亡率。采用多变量混合效应 Cox 回归。纳入了四项涉及 13193 例患者(男性 10479 例,女性 2714 例)的试验。在 5 年以上的随访中,女性发生 MACCE 的风险显著更高[调整后的危险比(HR)1.12,95%置信区间(CI)1.04-1.21;P=0.004],但死亡率相似(调整后的 HR 1.03,95%CI 0.94-1.14;P=0.51)。与男性相比,女性的 MI(调整后的 HR 1.30,95%CI 1.11-1.52)和再次血运重建(调整后的 HR 1.22,95%CI 1.04-1.43)发生率更高,但卒中和复发(调整后的 HR 1.17,95%CI 0.90-1.52)发生率无差异。在 75 岁及以上的患者中,性别间 MACCE 的差异无统计学意义。非体外循环手术和多动脉旁路移植术的使用并未改变性别间的差异。
女性在 CABG 后 5 年内的结局比男性差。在 75 岁以上的患者中,这种差异并不显著,且不受手术技术的影响。