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J Thorac Cardiovasc Surg 2004;128:487-488
© 2004 The American Association for Thoracic Surgery
Letter to the Editor |
a Division of Cardiovascular Surgery, St Vincent Mercy Medical Center, Toledo, Ohio
b Department of Medicine, Toledo, Ohio
c Department of Surgery, Medical College of Ohio, Toledo, Ohio
To the Editor:
Gender differences in the outcome of coronary artery bypass grafting (CABG) are currently a topic of much-deserved attention and debate. We read with interest the recent article in the Journal by Guru and colleagues1 in which they compared early and late outcomes in men versus women for the 1991-2000 Ontario, Canada CABG experience (n = 54,425). The authors' conclusions were as follows: (1) early CABG mortality is higher in women, even after adjustment for covariate predictors; (2) the risk of mortality in women becomes equivalent or better than that in men by 1 year after CABG; and (3) future research should focus on ways to reduce early mortality in women. We wish to comment, with a focus on early CABG outcomes.
We believe that, as written, the above conclusions might be inadvertently misleading because they suggest to the reader that female gender is itself a culprit in worse early CABG outcomes either directly or indirectly through some yet undetermined gender-related variable or variables. This is surprising because it ignores the authors' own data.1 Specifically, in the 13,921 patients in whom body surface area (BSA) was available, they found no gender differences in early mortality (hazard ratio, 1.04; P = .72) after adjusting for BSA in addition to the other predictors. We therefore contend that Guru and colleagues1 should have perhaps more accurately concluded that worse early mortality in women is present but is explained by their greater propensity for small body size. A recent article in this Journal supports this contention. Koch and associates2 convincingly demonstrated that female gender per se is not a cause of worse operative mortality. Their analysis of The Cleveland Clinic CABG experience revealed that early CABG mortality is essentially identical in male versus female patients (2.3% vs 2.1%; n = 945 each; P = .76) when patients are rigorously matched for demographics, including body habitus, risk factors, medications, coronary disease, and cardiopulmonary bypass (CPB).
In discussing their data, Guru and colleagues1 stated the following: "Women tended to have a lower body size, although their distribution of BSA values did overlap with that of men. In view of this fact, the neutralization of early mortality by adjustment with BSA might have occurred partially because BSA served as a surrogate marker for sex." Equally plausible, one can say that female gender is simply a surrogate marker of small size. Also, although it is true that the BSA distributions in men and women overlap, one cannot ignore that they are significantly different. Indeed, among patients undergoing CABG, women are disproportionately represented at both extremes of body size (small and obese), with important implications on outcome.3 Until matched comparisons, including for body size, demonstrate different outcomes for men versus women, we should not ignore the most compelling objective data, which thus far exculpate female gender.1,2
We also suggest that adopting a "small size–worse early outcomes" as opposed to the authors' "women–worse early outcome" perspective to the issue at hand is advantageous because (1) it is more precise and does not ignore the true potential for worse outcomes in small-sized men as well,4 and (2) it is helpful because it perhaps appropriately directs future research efforts toward gaining a better understanding of how and why size alters outcomes in this era of CABG. For example, at least when CPB is used, there is gathering evidence that on-pump hemodilutional anemia is particularly prevalent in smaller patients and might be a major cause of morbidity and mortality.4,5 Importantly, this role for hemodilution severity during CPB in CABG outcomes is a gender-shared, readily testable hypothesis, and investigating it will simultaneously address (1) the issues of optimizing CPB circuit design and practices and (2) the outcome concerns in women and small patients.
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