Heart surgery not as safe for older women

Heart surgery not as safe for older women

Last Thanksgiving, Cynthia Mosson stayed up all day in her kitchen in Frankfort, Indiana, cooking dinner for nine people. She was almost finished – the ham in the oven, the dressing prepared – when she suddenly felt the need to sit down.

“I started having pain in my left shoulder,” Ms. Mosson, 61, said. “It became very intense and started moving down my left arm.” She became sweaty and pale and told her family, “I think I’m having a heart attack.” »

An ambulance took her to hospital where doctors confirmed she had suffered a mild heart attack. They said tests revealed serious blockages in all of her coronary arteries and told her, “You’re going to need open heart surgery,” Ms. Mosson recalled.

When these patients walk into an operating room, 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 consequences following an operation called coronary artery bypass grafting.

CABG (pronounced like the vegetable) restores blood flow by harvesting arteries from patients’ arms or chests, as well as veins from their legs, and using them to bypass blocked blood vessels.

“It is the most common heart operation in the United States,” occurring between 200,000 and 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 death rate from CAP, although low, is much higher in women (2.8%) than in men (1.7%), Dr. Gaudino and colleagues found.

Analyzing the results of approximately 1.3 million patients (average age: 66 years) from 2011 to 2020, researchers also determined that after CABG, approximately 20% of men experienced complications, including stroke. brain damage, kidney failure, repeated surgical procedures, sternum infections and prolonged ventilation. use and hospital stays. Among women, more than 28 percent did so.

Of these complications, “many are relatively minor and resolve on their own,” Dr. Gaudino said. But recovering from a sternal wound infection can take months, he noted, and “if you have a stroke, it can affect you for a long time.” Although outcomes have improved for both sexes over the decade, the gender gap remains.

The study “should be considered a blast in the sky for all clinicians who care for women.” an accompanying editorial said. Yet to cardiology researchers, the results seemed familiar.

“This is something we’ve known about 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 among American women.

With the PAC, “the general assumption was that the situation was improving because technology, knowledge, skills and training were improving,” she said. Seeing the gender disparity persist “is very disappointing.”

Several factors help to 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 may include fatigue, shortness of breath, and back or stomach pain.

Less than 20 percent of patients enrolled in clinical trials were women, so “what we’ve learned is mostly based on research on men,” he added.

Partly because they are older – about 40% are over 70 – women are more likely than men to have developed health problems like diabetes, high blood pressure and vascular problems, “all factors that increase risk in cardiac surgery,” said Dr. Gaudino. . They also have smaller, more fragile blood vessels, which can make surgery more complex.

THE disparities affect other forms of cardiac treatment and surgery too. Women have worse outcomes than men five years after receiving a stent, 2020 study finds review of randomized trials reported.

They are “less likely to be prescribed and take statins, and particularly less likely to take high-intensity statins, which are the most life-saving,” said Dr. Bairey Merz. “The list is lengthened increasingly.”

When the PAC works well, the results can seem miraculous. Rhonda Skaggs, 68, underwent quadruple bypass surgery in July 2022 and spent 12 days in intensive care before returning home to Brooksville, Florida. Six months passed before she returned to work at a Home Shopping Network outlet store.

“Now you would never know I had open heart surgery,” she said. “I walk 10,000 steps a day. I teach line dancing classes twice a week. I got my life back.

But Susan Leary, 71, a retired teacher from New York who now lives in Fuquay-Varina, North Carolina, faces a second procedure after bypass surgery at Duke University last month.

“Women are less likely to have all the vessels bypassed that need to be bypassed,” said her cardiothoracic surgeon, Dr. Brittany Zwischenberger, co-author of the call to arms editorial in JAMA Surgery.

A few years earlier, Ms. Leary had sought a procedure to reduce the “ugly” varicose veins in her legs; now he lacked viable blood vessels for transplantation. “How did I know I was going to need some of these veins for my heart?” she says.

She underwent a double bypass, instead of the triple bypass she needed, representing “incomplete revascularization.”

“This may contribute to worse outcomes and future interventions,” Dr. Zwischenberger said. “Luckily, she is a candidate for a stent” for the blocked third artery, which involves inserting a mesh tube into the vessel to widen it. The procedure is scheduled for next month.

Proponents of improved care for women say their surgical risks can be reduced.

Dr. Lamia Harik, a cardiothoracic surgery researcher at Weill Cornell Medicine, and colleagues found that nearly 40 percent of women’s mortality during CABG comes from interoperative anemia. (Their study is in press.)

This occurs when operating teams administer fluids to dilute patients’ blood during surgery, allowing them to use the large cardiopulmonary bypass machine (“the pump”) that keeps the blood oxygenated and fluid while surgeons perform the transplant.

“It’s something that’s modifiable,” Dr. Harik 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 began recruiting women, and only women, in two new clinical trials. The international ROMA study, the first all-female surgical trial, will examine two CABG techniques to see which produces the best results; Federally funded Recharge trial will compare stenting to CABG

“In the past, a lot of surgeons thought it was inevitable,” Dr. Gaudino said of gender differences. “Maybe they won’t go away, but they can be minimized. »

Ms Mosson said her surgeons were happy with the results of her quadruple bypass, although she was briefly readmitted to hospital for fluid in her lungs. She started a three-times-a-week program cardiac rehabilitation programrecommended for patients who have undergone bypass surgery, and finds that its endurance improves.

She is still dealing with the psychological consequences of her heart attack and surgery, as Ms. Skaggs did and as Ms. Leary still does. They describe shock – none had a history of heart disease – depression and anxiety. “I always fear this could happen again,” Ms Mosson said.

An antidote, for Ms. Leary, was being recruited to ROMA; Duke is one of the clinical trial sites. She jumped at the chance to sign up.

“Let me be a part of it,” she said. “Maybe my daughter will need this information one day.”

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Eric D. Eilerman

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