Last Thanksgiving, Cynthia Mosson was on her feet all day in her kitchen in Frankfort, Ind., preparing dinner for nine. He was almost done—the ham in the oven, the dressing made—when he suddenly felt the need to sit down.
“I started having pain in my left shoulder,” said Ms Mosson, 61. “It got really intense and started going down my left arm.” She became sweaty and pale and told her family: “I think I’m having a heart attack.”
An ambulance rushed her to hospital where doctors confirmed she had suffered a mild heart attack. They said the test revealed severe blockages in all her coronary arteries and told her: ‘You’re going to need open heart surgery,’ Ms Mosson recalled.
When such patients go into surgery, what happens next has a lot to do with their gender, a recent study in JAMA Surgery reported. The study reinforced years of research showing that male and female patients can have very different outcomes after a procedure called a coronary artery bypass graft.
CABG (pronounced like the vegetable) restores blood flow by taking arteries from patients’ arms or chest and veins from their legs and using them to bypass blocked blood vessels.
“It’s the most common heart procedure in the United States,” performed 200,000 to 300,000 times a year, said Dr. Mario Gaudino, a cardiothoracic surgeon at Weill Cornell Medicine and lead author of the study.
Twenty-five to 30 percent of CABG patients are women. How are they doing? The mortality rate for CABG, although low, is much higher for women (2.8 percent) than men (1.7 percent), Dr. Gaudino and colleagues found.
Analyzing results from about 1.3 million patients (average age: 66) from 2011 to 2020, the researchers also determined that after CABG, about 20 percent of men had complications including strokes, kidney failure, recurrent surgeries, chest infections and prolonged ventilator use. use and hospital stay. Among women, more than 28 percent did.
Of those complications, “many are relatively minor and resolve on their own,” Dr. Gaudino said. However, recovery from chest infections can take months, he noted, and “if you have a stroke, that can affect you for a long time.” Although outcomes improved for both sexes over the decade, the gender gap remained.
The study “should be seen as a sky-rocket for all clinicians who care for women,” an accompanying article said. However, to the heart researchers, the results sounded familiar.
“This has been something we’ve known since the 1980s,” said Dr. C. Noel Bairey Merz, a cardiologist and researcher at Cedars-Sinai Medical Center. Heart disease, she pointed out, remains the leading cause of death for American women.
With CABG, “the general assumption was that it was improving because technology, knowledge, skills and training were all improving,” he said. Seeing gender inequality persist “is very disappointing”.
Several factors help explain these differences. Women are three to five years older than men when they undergo bypass surgery, in part because “we recognize coronary artery disease more easily and earlier in men,” Dr. Gaudino said. “Men have the classic presentation that we study in medical school. Women have different symptoms.” These can include fatigue, shortness of breath and back or stomach pain.
Fewer than 20 percent of patients enrolled in clinical trials were women, so “what we’ve been taught is essentially based on research in men,” he added.
Partly because they are older — about 40 percent are over 70 — women are more likely than men to have health problems such as diabetes, high blood pressure and vascular disease, “all factors that increase the risk of heart surgery.” , said Dr. Gaudino. . They also have smaller, more fragile blood vessels, which can make surgery more complicated.
The differences also affect other forms of cardiac treatment and surgery. Women have worse outcomes than men five years after getting a stent, according to a 2020 review of randomized trials.
They are “less likely to be prescribed and take statins, and especially less likely to take the high-intensity statins, which are the most life-saving,” said Dr. Bairey Merz. “The list goes on and on.”
When CABG works well, the results can be miraculous. Rhonda Skaggs, 68, underwent a quadruple bypass in July 2022 and spent 12 days in intensive care before going home to Brooksville, Florida. It was six months before she returned to her job at a Home Shopping Network store.
“Now, you’d never know I had open-heart surgery,” he said. “I walk 10,000 steps a day. I teach line dance classes twice a week. I have my life back.”
But Susan Leary, 71, a retired New York teacher who now lives in Fuquay-Varina, NC, is facing a second operation after undergoing bypass surgery at Duke University last month.
“Women are less likely to have all the vessels that need to be bypassed,” said her cardiothoracic surgeon, Dr. Brittany Zwischenberger, co-author of the call-to-arms article in JAMA Surgery.
A few years earlier, Ms Leary had sought a procedure to shrink the “ugly” varicose veins on her legs. now, she lacked viable blood vessels for grafting. “How did I know I would need some of these veins for my heart?” he said.
He did a double bypass, instead of the required triple bypass, which represents “incomplete revascularization.”
“It may contribute to worse outcomes and future interventions,” Dr. Zwischenberger said. “Luckily, she’s a candidate for a stent” for the third blocked artery, which involves inserting a mesh tube into the vessel to widen it. The procedure is scheduled for next month.
Advocates of improved care for women argue that their surgical risks can be reduced.
Dr. Lamia Harik, a cardiothoracic surgery researcher at Weill Cornell Medicine, and her colleagues found that nearly 40 percent of women’s mortality during CABG comes from perioperative anemia. (Their study is in press.)
This happens when surgical teams administer fluids to thin patients’ blood during the procedure, allowing them to use the large cardiopulmonary bypass machine (‘the pump’) that keeps blood oxygenated and flowing while surgeons perform the transplant .
“This is something that can be modified,” Dr. Harrick said. For women, surgeons may use smaller pumps or reduce the volume of fluid added, or both.
To learn more, Dr. Gaudino and other researchers have begun enrolling women, and only women, in two new clinical trials. The international ROMA study, the first all-female surgical trial, will investigate two CABG techniques to see which produces better results. the federally funded Recharge trial will compare stenting with CABG
“In the past, many surgeons thought this was inevitable,” Dr. Gaudino said of the gender differences. “Maybe they won’t go away, but they can be minimized.”
Ms Mosson said her surgeons were pleased with the results of the quadruple bypass, although she was readmitted to hospital briefly for fluid in her lungs. She has started a three-times-weekly cardiac rehab program, which is recommended for patients who have undergone bypass surgery, and is finding that her endurance is improving.
She is still dealing with the psychological effects of the heart attack and surgery, as Ms. Skaggs did and Ms. Leary still does. They describe shock — none had a history of heart disease — depression and anxiety. “I still struggle with the fear of it happening again,” Ms Mosson said.
An antidote, for Ms. Leary, was recruiting for ROMA. Duke is among the clinical trial sites. Grab the chance to register.
“Let me be a part of it,” he said. “Maybe my daughter will need this information someday.”
