Women with severe coronary heart disease causing narrowing or blockages in the arteries may derive greater long-term benefits from coronary artery bypass grafting compared with percutaneous coronary intervention, also known as stenting, according to a large study by Weill Cornell Medicine investigators. Bypass surgery uses a blood vessel from another part of the body to reroute blood flow around a narrowed or blocked artery. Stenting is a minimally invasive procedure that uses a catheter to thread a tubelike stent through a blood vessel in the wrist or groin to the heart to open a fully or partially blocked artery.
The study, published Nov. 25 in the European Heart Journal, adds much-needed evidence to guide decisions for women with heart disease—the leading cause of death among women. Historically, women have made up just 20% to 25% of large, prospective clinical trials comparing bypass surgery and stenting, making it hard to draw conclusions about their outcomes.
Dr. Mario Gaudino
“If you are a man, and you need coronary revascularization, you will receive what we call evidence-based treatment, because there is strong evidence to guide your treatment decision,” said senior author Dr. Mario Gaudino, the Stephen and Suzanne Weiss Professor in Cardiothoracic Surgery II at Weill Cornell Medicine and a cardiothoracic surgeon at NewYork-Presbyterian/Weill Cornell Medical Center. “If you are a woman, that's not the case. We don't have data, and so we use the data generated in men. However, we all know that women are not small men.”
Heart disease in women has many distinct characteristics. Women tend to develop coronary artery disease later in life and present with different symptoms than men, which often leads to delayed diagnoses. Women also have smaller, more vasoreactive coronary arteries, and more coronary microvascular disease compared with men.
Dr. Gaudino and his team partnered with University of Toronto investigators to analyze outcomes in all women in Ontario, Canada younger than 80 years of age who had extensive high-risk artery blockages and underwent stenting or bypass surgery between 2012 and 2021. A subset of 4,066 women were matched by their characteristics to emulate a randomized clinical trial. The dataset included, on average, five years of follow-up data for each woman.
“We were very fortunate to have access to this unique dataset,” 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 while a research fellow in cardiothoracic surgery at Weill Cornell Medicine. “It allowed us to look at a large number of women with severe coronary artery disease in a real-world setting and follow their long-term outcomes.”
Dr. Kevin An
They found that about 36% of the women who underwent stenting had a major cardiovascular event, such as a heart attack, stroke, need for repeat coronary revascularization, or were readmitted to the hospital for a heart condition or stroke. By comparison, only 22% of the women who underwent bypass surgery had such an event. Women who underwent stenting also had about a 30% higher risk of dying from any cause during the entire follow-up period than women who underwent bypass. During the first six months after the procedures, however, death risks were similar between the two groups.
“Over the long term, bypass surgery seems to be more protective compared to stenting,” said Dr. An. There was, however, one trade-off: women who underwent stenting had a slightly lower stroke risk than women who underwent bypass surgery.
“Currently, women are about half as likely to undergo bypass surgery as men,” said Dr. An. “More definitive data are 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 fill that evidence gap.
“For now, treatment decisions should remain individualized,” said Dr. An. “Although our study suggests that bypass surgery may offer more long-term protection compared to stents, anatomical considerations, individual surgical risk, and patient preferences remain critical.”
This study was supported by ICES, a research institute that is funded by an annual grant from Ontario’s Ministry of Health and Ministry of Long Term Care. The authors acknowledge that the clinical registry data used in this publication is from participating hospitals through CorHealth Ontario, which is funded by and serves as an advisory body to Ontario’s Ministry of Health. Parts of this material are based on data and/or information compiled and provided by the Canadian Institute for Health Information and Ontario’s Ministry of Health.
