Women may receive greater long-term benefits from coronary artery bypass surgery compared to stents

Women may receive greater long-term benefits from coronary artery bypass surgery compared to stents

Women with severe coronary artery disease that causes narrowing or blockages in the arteries may receive greater long-term benefits from a coronary artery bypass graft than with percutaneous coronary intervention, also known as stenting, according to a large study by Weill Cornell Medicine researchers. Bypass surgery uses a blood vessel from another part of the body to redirect blood flow around a narrowed or blocked artery. Stenting is a minimally invasive procedure in which a catheter is used to pass a tubular stent through a blood vessel in the wrist or groin to the heart to open a partially or completely blocked artery.

The study, published November 25 in the European Heart Journal, provides much-needed evidence to guide decision-making for women with heart disease - the leading cause of death in women. Historically, women accounted for only 20 to 25% of large, prospective clinical trials comparing bypass surgery and stenting, making it difficult to draw conclusions about their outcomes.

If you are a man and need coronary revascularization, you will receive what is called evidence-based treatment because there is strong evidence to guide your treatment decision. If you are a woman, that is not the case. We have no data and therefore use the data generated in men. However, we all know that women are not little men.”

Dr. Mario Gaudino,senior author,the Stephen and Suzanne Weiss Professor of Cardiothoracic Surgery II at Weill Cornell Medicine and cardiothoracic surgeon at NewYork-Presbyterian/Weill Cornell Medical Center

Heart disease in women has many different characteristics. Women tend to develop coronary artery disease later in life and present with different symptoms than men, often leading to delayed diagnoses. Women also have smaller, more vascularly active coronary arteries and higher rates of coronary microvascular disease compared to men.

Gaudino and his team worked with researchers at the University of Toronto to analyze the results of all women in Ontario, Canada, who are younger than 80 years old and had severe, high-risk artery blockages and underwent stenting or bypass surgery between 2012 and 2021. A subset of 4,066 women were matched based on their characteristics to mimic a randomized clinical trial. The data set included an average of five years of follow-up data for each woman.

“We were very fortunate to have access to this unique data set,” said lead author Dr. Kevin An, a clinical fellow in cardiothoracic transplantation and mechanical circulatory support at NewYork-Presbyterian/Columbia University Irving Medical Center, who conducted this research as a research fellow in cardiothoracic surgery at Weill Cornell Medicine. “It allowed us to study large numbers of women with severe coronary artery disease in a real-world setting and track their long-term outcomes.”

They found that about 36% of women who underwent stenting had a major cardiovascular event, such as a heart attack or stroke, the need for repeat coronary revascularization, or were readmitted to the hospital for heart disease or stroke. In comparison, only 22% of women who underwent bypass surgery experienced such an event. Women who had stent implantation also had about a 30% higher risk of dying from any cause throughout the follow-up period than women who had bypass surgery. However, in the first six months after the procedures, the risk of death was similar in both groups.

“In the long term, bypass surgery appears to be more protective compared to stenting,” said Dr. To. However, there was a trade-off: Women who had stent implantation had a slightly lower risk of stroke than women who had bypass surgery.

“Currently, women are about half as likely as men to undergo bypass surgery,” said Dr. To. “More definitive data is needed to change practice guidelines,” said Dr. Gaudino. He and his team are conducting a large prospective clinical trial comparing the two interventions in women with severe coronary artery disease to address this evidence gap.

“For now, treatment decisions should remain individual,” said Dr. To. “Although our study suggests that bypass surgery provides longer-term protection compared to stents, anatomical considerations, individual surgical risk and patient preference remain critical.”

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