Interact CardioVasc Thorac Surg 2009;9:823-826. doi:10.1510/icvts.2009.213249
© 2009 European Association of Cardio-Thoracic Surgery
Institutional report - Carotid and imaging |
Is there any difference in carotid stenosis between male and female patients undergoing coronary artery bypass grafting?
Stavros Siminelakisa,*,
Angeliki Kotsantia,
Michael Siafakasb,
George Dimakopoulosa,
Socrates Sismanidisa,
Michael Koutentakisa,
Constantine Paziourosa and
George Papadopoulosc
a Department of Cardio-Thoracic Surgery, University Hospital of Ioannina, Greece
b Department of Radiology, University Hospital of Ioannina, Greece
c Department of Anesthesiology, University Hospital of Ioannina, Greece
Received 30 May 2009;
received in revised form 24 July 2009;
accepted 29 July 2009
 Presented in part in the 18th WSCTS World Congress, World Society of Cardio Thoracic Surgeons, Kos, Greece, 30 April–3 May 2008.
*Corresponding author. Bouboulinas 34, Ioannina, 45445 Greece. Tel.: +2651099681; fax: +2651099677.
E-mail address: ssiminel{at}yahoo.com (S. Siminelakis).
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Abstract
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Cardiovascular diseases are among the leading causes of death in women. Significant gender differences have been reported among patients with symptomatic carotid artery disease. The aim of this study is to examine if the female sex is a predisposing factor for carotid stenosis in coronary artery bypass grafting (CABG) patients. We studied 965 CABG patients, 796 males and 169 females. We combined the gender with risk factors predicting carotid disease as a history of cerebrovascular accident (CVA), peripheral vascular disease (PVD), left main (LM) disease and advanced age. We compared the incidence of carotid disease for each gender against known risk factors, which are history of CVA, PVD, LM and advanced age. In our study, there was not a statistically significant difference for the presence of carotid disease between males and females undergoing CABG. However, patients with a history of CVA, with PVD and older age were at greater risk for carotid stenosis. We conclude that the female sex is not a predictive factor for carotid stenosis in CABG patients.
Key Words: Coronary disease; Cerebral protection; Peripheral Vascular; Myocardial protection
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1. Introduction
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Atherosclerotic diseases, especially coronary and cerebrovascular disease, are among the leading causes of death in women in the US. Forty percent of all coronary events are fatal and stroke is one of the leading causes of severe disability in women [1].
Women undergoing CABG in several series have a higher morbidity and mortality as well as less relief of symptoms. Comorbid conditions and risk factors are more frequent in women compared with men and also women have higher rates of neurological complications and acute myocardial infarction after the procedure [2, 3]. The etiology of cerebrovascular accident (CVA) after CABG is multifactorial and it is often difficult to determine which mechanism is implicated in a particular patient. Significant carotid stenosis is also associated with longer hospitalization and higher in-hospital mortality rates, but carotid stenosis is potentially treatable and is detectable before or during operation.
The purpose of this study is to report the incidence of carotid disease in female candidates for CABG and to examine whether being female is a predisposing factor for carotid stenosis in these patients.
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2. Methods
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Between January 2000 and June 2007, 965 patients underwent CABG, 169 (17.5%) females and 796 (82.5%) males. Patients undergoing urgent or emergency operations and patients who had carotid endarterectomy (CEA) prior to CABG were also included. Patients who underwent valve replacement or repair, aneurysmectomy, atrial septal defect closure, aortic or salvage operations were excluded.
Patients were divided for descriptive reasons of our sample into two groups (male and female) and each one further subdivided into four groups according to the presence of risk factors for carotid stenosis [history of CVA, peripheral vascular disease (PVD), left main (LM) disease and age >65 years] [4, 5].
All patients had a carotid color duplex examination before CABG; when the duplex was inconclusive CT angiography was performed. The common, internal, external carotid arteries and the vertebral arteries were examined bilaterally for the presence of occlusion or stenosis. The degree of stenosis was expressed as the percentage of luminal narrowing.
EuroSCORE is a method of calculating the predicted operative mortality for patients undergoing cardiac surgery. When patient risk factors are taken into consideration, operative mortality is a good estimate of the quality of cardiac surgical care, therefore EuroSCORE was meticulously calculated. The higher the score, the worse the prognosis.
 2 Tests were applied as well as Mann–Whitney tests in order to detect significant associations between variables. Significant results were analyzed with logistic regression. The significance level was set in all cases to 95%.
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3. Results
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The percentage of female patients having carotid stenosis >50% was 50% in the history of CVA group, 10% in the PVD group, 14.2% in the age  65 years and 16.7% in the age <65 years group. These rates were not statistically different from the observed rates in males. The average values of EuroSCORE are greater for females with PVD history, age <65 years and marginally greater for age >65 years. These show statistically significant differences between males and females (Table 1).
It is observed that the incidence of carotid stenosis in patients >65 years is independent from the presence of LM disease and gender (Table 2).
The incidence of postoperative stroke in our study population is 0.72% (7 patients). 1.2% of our female population suffered a postoperative stroke and 0.63% was the rate in males. 42.85% of the patients who suffered postoperative stroke had a history of CVA and the mortality rate in our patients with CVA was 28.6% (Table 3).
Significant results were analyzed with logistic regression. We observe that significant predicting factors of carotid stenosis are history of CVA (P=0.000), PVD (P=0.022) and age (P=0.001) (Table 4).
The odds of a >50% carotid stenosis are: 3.57 times greater (95% CI 1.92–6.6) for CVA patients, 2.03 times greater (95% CI 1.36–3.05) for older patients, and 1.90 times greater (95% CI 1.1–3.32) for PVD patients.
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4. Discussion
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In this study we compared the incidence of carotid disease for each gender against the known risk factors of: history of CVA, PVD, LM and advanced age. Durand et al. [5] with univariate analysis and D'Agostino et al. [6] with multivariate analysis identified an age >65 years, PVD, prior CVA, left main coronary disease of >50%, female gender, and hypertension as risk factors for significant carotid stenosis.
A number of earlier reports had suggested that being female was an independent risk factor for mortality and morbidity after CABG. More recent studies have suggested that women on average have a disadvantageous preoperative profile that accounts for much of this perceived difference [7, 8]. Once vascular disease becomes symptomatic the outcome for women has been suggested to be worse than for men and maybe due to multifactorial causes [7, 8].
The hormonal biology, delaying presentation, a higher prevalence of smoking in the female population over the last decades, a markedly higher prevalence of diabetes in younger women compared to younger men, and anatomic differences, such as smaller vessel size and the smaller mean body surface area have all been considered negative predictors for atherosclerotic diseases [1, 2].
In our study, the mean EuroSCORE values were greater for females compared with males, in all the subgroups but were statistically different between genders in patients with PVD history, age <65 years and marginally greater for age 65 years. Thus, women undergoing CABG are at a greater risk than men. Researchers have proposed that women with premature coronary artery disease have unknown risk factors or lack of protective factors normally present in women. Women <50 years of age had the highest hospital mortality compared with men in the same age range. Among the oldest patients (80 years), the in-hospital death rate was only slightly higher in women compared with men. Differences in mortality between genders reduce as age increases [9].
Toumpoulis et al. [10] found that despite both genders having the same odds for early outcome and the superiority of females in long-term survival, there are three independent predictors for long-term mortality after CABG unique for women compared with 12 for men.
Weintraub et al. [11] noted that the risk of death after CABG has increased in women more than in men because, in comparison, women are consistently older, have diabetes, need urgent surgery and in recent years more women undergoing CABG have a three-vessel or LM disease. Aldea et al. [12] reported that the incidence of LM is the same for both genders. In our study, the prevalence of carotid stenosis >50% in patients with LM was not statistically different in females compared with males.
Regarding the multifactorial nature of perioperative stroke in CABG patients, significant carotid stenosis plays an important role per se, and when combined with other factors the effect is substantial [5]. Carotid disease may cause stroke by predisposing to low flow in the presence of systemic hypotension or merely a modest decrease of systemic blood pressure. Also, carotid occlusive disease can be the source of artery-to-artery embolism.
In our study, the incidence of postoperative stroke was twice as much for women. These results are similar to the results in other studies throughout the years. Hogue et al. [13], after adjusting risk factors by multivariate logistic regression analysis, found that female sex was independently associated with increased risk of neurological complications after cardiac surgery. Because increased susceptibility for neurological complications in women undergoing CABG cannot be explained by traditional risk factors, a question is raised whether low circulating estrogens might play a role. Brandrup-Wognsen et al. [14] noted that the incidence of postoperative stroke was twice as much in women.
In contrast to other researchers, Aldea et al. [12] concluded that the incidence of death, perioperative myocardial infarction and CVA after CABG in women and men were not statistically significant, after accounting for differences in their risk variables.
Goto et al. [15] reported that men are more likely than women to have risk factors for stroke, including severe carotid artery stenosis, severe aortic atherosclerosis, and peripheral vascular disease. Both genders had similar rates of prior cerebral infarction and preoperative cognitive impairment.
Concerning the observed in our paper, higher incidence of history of CVA in females and the higher incidence of carotid stenosis in younger females they are not statically significant, as logistic regression did not show a significant effect on carotid stenosis of gender (P=0.351), of its interaction with the age category (P=0.618) nor of its interaction with CVA (P=0.230).
The odds of a >50% carotid stenosis are: 3.57 times greater (95% CI 1.92–6.6) for CVA patients, 2.03 times greater (95% CI 1.36–3.05) for older patients, and 1.90 times greater (95% CI 1.1–3.32) for PVD patients.
Durand et al. [5] and D'Agostino et al. [6] identified an age >65 years, PVD, prior CVA, left main coronary disease of >50%, female gender, and hypertension as risk factors for significant carotid stenosis.
In our study, we compared the incidence of carotid disease for each gender against known risk factors, that is, history of CVA, PVD, LM and advanced age. With the use of logistic regression analysis we observed that significant predicting factors of carotid stenosis are history of CVA (P=0.000), PVD (P=0.022) and age (P=0.001).
Female gender is not a predictive factor for carotid stenosis in CABG patients; however, women undergoing CABG are at greater risk for major complications than men because of the comorbid conditions that are associated with the later age at which women present for coronary surgery and not because of gender.
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References
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- Roddy SP, Darling RC 3rd, Abrishamchian AR, Ozsvath KJ, Kreienberg PB, Paty PS, Mehta M, Chang BB, Shah DM. Combined coronary artery bypass with carotid endarterectomy: do women have worse outcomes? J Vasc Surg 2002 Sep;36:555–558.[CrossRef][Medline]
- Vaccarino V, Abramson JL, Veledar E, Weintraub WS. Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women. Circulation 2002 Mar 12;105:1176–1181.[Abstract/Free Full Text]
- Hirotani T, Kameda T, Kumamoto T, Shirota S, Yamano M. Stroke after coronary artery bypass grafting in patients with cerebrovascular disease. Ann Thorac Surg 2000;70:1571–1576.[Abstract/Free Full Text]
- Naylor AR, Mehta Z, Rothwell PM, Bell PRF. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg 2002;23:283–294.[CrossRef][Medline]
- Durand DJ, Perler BA, Roseborough GS, Grega MA, Borowicz LM Jr, Baumgartner WA, Yuh DD. Mandatory versus selective preoperative carotid screening: a retrospective analysis. Ann Thorac Surg 2004;78:159–166.[Abstract/Free Full Text]
- D'Agostino RS, Svensson LG, Neumann DJ, Balkhy HH, Williamson WA, Shahian DMl. Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients. Ann Thorac Surg 1996;62:1714–1723.[Abstract/Free Full Text]
- ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery. Executive Summary and Recommendations. Circulation 1999;100:1464–1480.[Free Full Text]
- Blankstein R, Ward RP, Arnsdorf M, Jones B, Lou YB, Pine M. Female gender is an independent predictor of operative mortality after coronary artery bypass graft surgery: contemporary analysis of 31 midwestern hospitals. Circulation 2005;112:I-323–I-327.[Abstract/Free Full Text]
- Tan ES, van der Meer J, Jan de Kam P, Dunselman PH, Mulder BJ, Ascoop CA, Pfisterer M, Lie KI. Worse clinical outcome but similar graft patency in women versus men one year after coronary artery bypass graft surgery owing to an excess of exposed risk factors in women. CABADAS. Research Group of the Interuniversity Cardiology Institute of The Netherlands. Coronary artery bypass graft occlusion by aspirin, dipyridamole and acenocoumarol/phenoprocoumon study. J Am Coll Cardiol 1999;34:1760–1768.[Abstract/Free Full Text]
- Toumpoulis IK, Anagnostopoulos CE, Balaram SK, Rokkas CK, Swistel DG, Ashton RC Jr, De Rose JJ Jr. Assessment of independent predictors for long-term mortality between women and men after coronary artery bypass grafting: are women different from men. J Thorac Cardiovasc Surg 2006;131:343–351.[Abstract/Free Full Text]
- Weintraub WS, Wenger NK, Jones EL, Craver JM, Guyton RA. Changing clinical characteristics of coronary surgery patients. Differences between men and women. Circulation 1993;88:II79–II86.[Medline]
- Aldea GS, Gaudiani JM, Shapira OM, Jacobs AK, Weinberg J, Cupples AL, Lazar HL, Shemin RJ. Effect of gender on postoperative outcomes and hospital stays after coronary artery bypass grafting. Ann Thorac Surg 1999;67:1097–1103.[Abstract/Free Full Text]
- Hogue CW Jr, Barzilai B, Pieper KS, Coombs LP, De Long ER, Kouchoukos NT, Davila-Roman VG. Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report. Circulation 2001;103:2133–2137; Review.[Abstract/Free Full Text]
- Brandrup-Wognsen G, Berggren H, Hartford M, Hjalmarson A, Karlsson T, Herlitz J. Female sex is associated with increased mortality and morbidity early, but not late, after coronary artery bypass grafting. Eur Heart J 1996;17:1426–1431.[Abstract/Free Full Text]
- Goto T, Baba T, Ito A, Maekawa K, Koshiji T. Gender differences in stroke risk among the elderly after coronary artery surgery. Anesth Analg 2007;104:1016–1022.[Abstract/Free Full Text]
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Abstract
1. Introduction
