Unsafe heart surgery for older women

Unsafe heart surgery for older women

Last Thanksgiving, Cynthia Musson was on her feet all day in her kitchen in Frankfort, Indiana, preparing dinner for nine people. She was almost done—pork in the oven, sauce—when she suddenly felt the need to sit down.

Mrs Mawson, 61, said: “I started to feel pain in my left shoulder. The pain became very severe and started to go 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 the hospital where doctors confirmed that she had suffered a mild heart attack. They said the test revealed serious blockages in all of her coronary arteries, and they told her: “You’re going to need open-heart surgery,” Ms Mawson recalled.

When these patients head to the operating room, what happens next has a lot to do with their gender, a recent study in JAMA Surgery reported. The study reinforces years of research showing that male and female patients can have very different outcomes after a procedure called coronary artery bypass grafting.

Coronary artery bypass grafting (CABG) restores blood flow by taking arteries from patients’ arms or chests, and veins from their legs, and using them to bypass blocked blood vessels.

“It is the most common heart procedure in the United States, performed 200,000 to 300,000 times a year,” said Dr. Mario Gudino, a cardiothoracic surgeon at Weill Cornell Medical College and lead author of the study.

Twenty-five to 30 percent of CABG patients are women. How do you fare? Dr. Godino and his colleagues found that the death rate from CABG, although low, is much higher for women (2.8 percent) than for men (1.7 percent).

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 developed complications that included strokes, kidney failure, repeat surgeries, and sternum infections. And a ventilator for long periods. Employment and hospital stay. Among women, more than 28 percent did so.

Of those complications, “many are relatively minor and self-resolving,” Dr. Godino said. But recovery from sternal wound infections can take months, and “if you have a stroke, it can affect you for a long time.” Although outcomes for both sexes improved over the decade, the gender gap remained.

“The study should be viewed as an exploding flame in the sky for all physicians who care for women,” an editorial accompanying the study said. However, the results seemed familiar to heart researchers.

Dr. C. said: “We’ve known this since the 1980s,” said Noel Byre-Mears, a cardiologist and researcher at Cedars-Sinai Medical Center. She noted that heart disease remains the leading cause of death for American women.

With CABG, “the general assumption was that it was getting better because the technology, knowledge, skills and training were all getting better,” she said. Seeing the gender disparity persist is “very disappointing.”

There are several factors that help explain these differences. Women are three to five years older than men when they undergo heart bypass surgery, in part because “we recognize coronary artery disease more easily and earlier in men,” Dr. Godino said. “Men have the classic symptom that we study in medical school. Women have different symptoms.” These symptoms may include fatigue, shortness of breath, and pain in the back or stomach.

He added that less than 20% of patients enrolled in clinical trials were female, so “what we have learned is based primarily on research conducted on men.”

Partly because they are older — about 40 percent over age 70 — women are more likely than men to have health problems such as diabetes, high blood pressure, and vascular disease, “all of which increase the risk of heart surgery,” Dr. Godino said. . . They also have smaller, more fragile blood vessels, which can make surgery more complicated.

Disparities affect other forms of heart treatment and surgery as well. Women have worse outcomes than men five years after having the stent fitted, a 2020 review of randomized trials reported.

“They are less likely to be prescribed and take statins, and especially less likely to take high-intensity statins, which are the most life-saving,” Dr. Byre-Mears said. “The list goes on and on.”

When coronary artery bypass grafting (CABG) 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 in a Home Shopping Network store.

“Now, you would never know I had open-heart surgery,” she said. “I walk 10,000 steps a day. I teach line dancing lessons twice a week. I have life again.”

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

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

A few years ago, Ms. Leary sought an operation to shrink “unsightly” varicose veins in her legs; She now lacks suitable blood vessels for grafting. “How did you know I would need some of those veins for my heart?” She said.

She had a double bypass, instead of the triple bypass she needed, which represented “incomplete revascularization.”

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

Advocates say improving care for women can reduce their surgical risks.

Dr. Lamia Harik, a cardiothoracic surgery researcher at Weill Cornell Medical College, and her colleagues found that nearly 40 percent of women’s deaths during CABG stem from anemia during surgery. (Their study in journalism.)

This occurs when operating teams administer fluids to thin patients’ blood during an operation, allowing them to use the large cardiopulmonary bypass machine (“pump”) that keeps the blood oxygenated and flowing while surgeons perform the grafting procedure.

“This is something that is modifiable,” Dr. Harrick said. For women, surgeons may use smaller pumps or reduce the volume of fluid added, or both.

To learn more, Dr. Godino and other researchers have begun enrolling women, and only women, in two new clinical trials. The international ROMA study, the first women-only surgical trial, will look at two CABG techniques to see which leads to better outcomes; The federally funded RECHARGE trial will compare stents with CABG

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

Ms Mawson said her surgeons were happy with the results of the quadruple bypass, although she was briefly readmitted to hospital due to fluid in her lungs. She began a three-times-weekly cardiac rehabilitation program, recommended for patients who have had bypass surgery, and found her endurance improved.

She still suffers from the psychological effects of her heart attack and surgery, as Mrs. Skaggs did and Mrs. Leary still does. They describe shock – none of them had a history of heart disease – depression and anxiety. Ms Mawson said: “I still struggle with the fear it will happen again.”

An antidote to Ms. Leary has been recruited for Rome. Duke is among the clinical trial sites. I took the opportunity to register.

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

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