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Ann Thorac Surg 1996;62:623
© 1996 The Society of Thoracic Surgeons
Department of Cardiac Surgery, Alhada Armed Forces Hospital, PO Box 1347, Taif,Saudi Arabia
To the Editor:
My colleagues and I believe, like many others [1–5], that coronary interventions or operations in female patients carry higher risk of morbidity and mortality than in male patients. Also the complication rate of coronary artery disease without treatment is much worse in female patients [1]. The Coronary Artery Surgery Study investigators implicated women's short stature and smaller coronary arteries in operative and technical difficulty [5]. The Framingham Heart Study established the differences in the clinical presentation and prognosis of coronary artery disease according to sex [6]. Loop and associates [3] and Wegner [7] reported that adverse preoperative prognostic indicators for bypass operations, including older age, severe or unstable angina requiring urgent or emergent intervention, previous infarction, heart failure, and a more advanced symptomatic or functional class, predominate in women despite the lower incidence of multivessel disease in female patients. The lower incidence of coronary artery disease in female patients is most probably attributed to the favorable effect of estrogen on the high-density lipoprotein cholesterol [1]. Khan and associates [4] explained that the higher mortality among women is due to their late referral at an older age and much sicker condition, rather than being related to their sex. The less favorable perioperative mortality in female patients reported from a number of prestigious centers including the Coronary Artery Surgery Study participants, the Cleveland Clinic, and the Emory University School of Medicine, may have further reduced the rate of referral of women for operation [3, 5].
Other factors behind the higher risk of cardiac surgery in female patients that we have found in our study (not yet published) besides the above-mentioned include a greater incidence of psychological problems and emotional lability and early and severe postmenopausal osteoporosis causing softer tissues and bones, which may require reinforced sternal closure to avoid dehiscence, especially after unilateral or bilateral mammary dissection in diabetic patients. The incidence of diabetes is also greater in female patients. Aspirin may have a less favorable effect on female patients than on male patients, which may predispose them to a higher occurrence of unstable angina, myocardial infarction, and graft failure. We have also found that the most common complications associated with female patients include perioperative myocardial infarction, sternal dehiscence, and respiratory failure requiring tracheostomy.
Although female sex is a strong risk factor in coronary disease, it is less obvious in valvular or adult congenital heart disease. Older women undergoing noncoronary operations still have higher risk than men.
References
3475 Torrance, Suite B, Torrance, CA 90503
To the Editor:
Doctor Al-Ebrahim reports that coronary artery operations in women carry a higher risk than in men, a fact that has been confirmed repeatedly. The Society of Thoracic Surgeons' national database reports that during 1994 to 1995, the mortality rate for coronary operations continues to be twice as high in women for isolated bypass grafting and also for aortic or mitral valve replacement combined with bypass grafting. In our own study [1], we attributed the difference to the higher incidence of diabetes in female patients, because in nondiabetic patients, male and female patients had the same probability of survival over the 15-year period of the study. We also found that younger age adversely affected survival, as noted in the Coronary Artery Surgery Study [2]. Clearly, factors specific to coronary atherosclerosis and its interrelationships with diabetes, lipid metabolism, estrogen, and thrombogenesis are contributing to the higher risk of coronary operations in female patients.
Al-Ebrahim suggests that psychological and emotional problems may also contribute to poor results in female patients. It is not clear how this could cause increased morbidity after an operation. In our study of health status after myocardial revascularization, women did report less satisfactory status postoperatively [1]. We recently repeated a similar questionnaire follow-up study for the years 1993 to 1995, again confirming that women do not feel as good as men after a cardiac operation: 83% of men (n = 453) reported being "very pleased" with their status, as opposed to 71% of women (n = 179) (
2 = 18.83; p < 0.001). Women may have different expectations than men. They also may have less complete revascularization, possibly because of smaller vessels, resulting in less effective symptomatic relief. This is a problem that should be technically correctable.
It is apparent that the gender gap in the application of coronary surgery has not been closed, or even reduced. The challenge remains.
References
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