Coronary artery bypass grafting in women: a review of literature

Abstract

The role of sex in coronary artery disease (CAD), including its treatment and prognosis, is complex and has been studied for several decades. It is well known that men and women differ physiologically and that the pathophysiology of CAD varies between sexes. Additionally, there are sex differences in outcomes after coronary artery bypass grafting (CABG), with women experiencing worse outcomes than men. A PubMed search was conducted using terms related to differences between men and women with CAD requiring CABG. We will discuss the status of CABG in women with respect to preoperative profile, surgical strategy, short- and long-term outcomes, and quality of life. The leading causes of these differences remain debated. Generally, women are older and have a greater clustering of risk factors at the time of CABG. In particular, short-term outcomes appear worse for women, while studies on long-term outcomes are contradictory. Women also report a worse quality of life after CABG and experience higher rates of depression.

Keywords

Male-Female differences / coronary artery bypass grafting / coronary artery disease

References

[1] Centraal bureau voor de statistiek (CBS). Available from https://opendata.cbs.nl/statline/#/CBS/nl/dataset/80202ned/table?ts=1734083164294 [accesses 8 December 2025].

[2] Libby P.Pathophysiology of coronary artery disease.Circulation2005;111:3481-8

[3] Lawton JS, Tamis-Holland JE, Bangalore S, et al.; Writing Committee Members. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol2022;79:197-215

[4] Hara H, Takahashi K, van Klaveren D, et al.; SYNTAX Extended Survival Investigators. Sex differences in all-cause mortality in the decade following complex coronary revascularization.J Am Coll Cardiol2020;76:889-99

[5] Guru V,Tu JV.Time-related mortality for women after coronary artery bypass graft surgery: a population-based study.J Thorac Cardiovasc Surg2004;127:1158-65

[6] Nashef SA,Michel P,Lemeshow S.European system for cardiac operative risk evaluation (EuroSCORE).Eur J Cardiothorac Surg1999;16:9-13

[7] Ad N,Speir AM.The performance of the EuroSCORE and the society of thoracic surgeons mortality risk score: the gender factor.Interact Cardiovasc Thorac Surg2007;6:192-5

[8] Kunadian V,Camici PG.An EAPCI expert consensus document on ischaemia with non-obstructive coronary arteries in collaboration with European Society of Cardiology Working Group on coronary pathophysiology & microcirculation endorsed by Coronary Vasomotor Disorders International Study Group.Eur Heart J2020;41:3504-20

[9] Cho L,Bakaeen F.Cardiac surgery in women in the current era: what are the gaps in care?.Circulation2021;144:1172-85

[10] Mansur Ade P,Takada JY.Long-term follow-up of a randomized, controlled clinical trial of three therapeutic strategies for multivessel stable coronary artery disease in women.Interact Cardiovasc Thorac Surg2014;19:997-1001

[11] Lansky AJ,Maehara A.Gender and the extent of coronary atherosclerosis, plaque composition, and clinical outcomes in acute coronary syndromes.JACC Cardiovasc Imaging2012;5:S62-72

[12] Pepine CJ,Lambert CR.Some thoughts on the vasculopathy of women with ischemic heart disease.J Am Coll Cardiol2006;47:S30-5

[13] Lawton JS.Sex and gender differences in coronary artery disease.Semin Thorac Cardiovasc Surg2011;23:126-30

[14] Jacobs AK,Brooks MM.Better outcome for women compared with men undergoing coronary revascularization: a report from the bypass angioplasty revascularization investigation (BARI).Circulation1998;98:1279-85

[15] Frishman WH,Hirsch H.Differences between male and female patients with regard to baseline demographics and clinical outcomes in the Asymptomatic Cardiac Ischemia Pilot (ACIP) Trial.Clin Cardiol1998;21:184-90 PMCID:PMC6655608

[16] Jamee A,Jalambo MO.Gender difference and characteristics attributed to coronary artery disease in Gaza-Palestine.Glob J Health Sci2013;5:51-6 PMCID:PMC4776843

[17] Vogel B,Kunadian V.Residual angina in female patients after coronary revascularization.Int J Cardiol2019;286:208-13

[18] Agarwala A,Samad Z,Virani SS.The use of sex-specific factors in the assessment of women’s cardiovascular risk.Circulation2020;141:592-9 PMCID:PMC7032610

[19] Maas AH.Gender differences in coronary heart disease.Neth Heart J2010;18:598-602 PMCID:PMC3018605

[20] Tamis-Holland JE, Lu J, Korytkowski M, et al.; BARI 2D Study Group. Sex differences in presentation and outcome among patients with type 2 diabetes and coronary artery disease treated with contemporary medical therapy with or without prompt revascularization: a report from the BARI 2D Trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes).J Am Coll Cardiol2013;61:1767-76

[21] Davis KB,Ryan T,Kennedy JW.Comparison of 15-year survival for men and women after initial medical or surgical treatment for coronary artery disease: a CASS registry study.J Am Coll Cardiol1995;25:1000-9

[22] Elkoustaf RA.Is there a gender paradox in the early invasive strategy for non ST-segment elevation acute coronary syndromes?.Eur Heart J2004;25:1559-61

[23] Shah SJ,Svedlund S.Prevalence and correlates of coronary microvascular dysfunction in heart failure with preserved ejection fraction: PROMIS-HFpEF.Eur Heart J2018;39:3439-50 PMCID:PMC6927847

[24] Mehta PK,Levit RD,Waheed N.Ischemia and no obstructive coronary arteries (INOCA): a narrative review.Atherosclerosis2022;363:8-21 PMCID:PMC9840845

[25] Nguyen LS,Brusset A.Heart failure with preserved ejection fraction as an independent risk factor of mortality after cardiothoracic surgery.J Thorac Cardiovasc Surg2018;156:188-193.e2

[26] Duca F,Kammerlander AA.Gender-related differences in heart failure with preserved ejection fraction.Sci Rep2018;8:1080 PMCID:PMC5773700

[27] Arslanian-Engoren C,Fang J.Symptoms of men and women presenting with acute coronary syndromes.Am J Cardiol2006;98:1177-81

[28] Lehtinen ML,Soletti G.Sex differences in saphenous vein graft patency: a systematic review and meta-analysis.J Card Surg2022;37:4573-8

[29] Gaudino M,Cao D.Sex-related outcomes of medical, percutaneous, and surgical interventions for coronary artery disease: JACC Focus Seminar 3/7.J Am Coll Cardiol2022;79:1407-25

[30] Woorst JF, van Straten AHM, Houterman S, Soliman-Hamad MA. Sex difference in coronary artery bypass grafting: preoperative profile and early outcome.J Cardiothorac Vasc Anesth2019;33:2679-84

[31] Serruys PW,Collet C.Outcomes after coronary stenting or bypass surgery for men and women with unprotected left main disease: the EXCEL Trial.JACC Cardiovasc Interv2018;11:1234-43

[32] Piña IL, Zheng Q, She L, et al.; STICH Trial Investigators. Sex difference in patients with ischemic heart failure undergoing surgical revascularization: results from the STICH Trial (surgical treatment for ischemic heart failure)..Circulation2018;137:771-80

[33] Kirov H,Toshmatov S.Survival trends of patients after coronary artery bypass grafting and sex-specific differences-a meta-analysis of reconstructed time-to-event data.Am J Cardiol2025;253:53-8

[34] Koch CG, Weng YS, Zhou SX, et al.; Ischemia Research and Education Foundation, Multicenter Study of Perioperative Ischemia Research Group. Prevalence of risk factors, and not gender per se, determines short- and long-term survival after coronary artery bypass surgery.J Cardiothorac Vasc Anesth2003;17:585-93

[35] Yusuf S, Hawken S, Ounpuu S, et al.; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.Lancet2004;364:937-52

[36] Walli-Attaei M,Rosengren A.Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.Lancet2020;396:97-109

[37] Wenger N.Tailoring cardiovascular risk assessment and prevention for women: one size does not fit all.Glob Cardiol Sci Pract2017;2017:e201701 PMCID:PMC5621718

[38] Campbell DJ,Jenkins AJ.Differences in myocardial structure and coronary microvasculature between men and women with coronary artery disease.Hypertension2011;57:186-92

[39] Wang Y,Jiao Y.Sex differences in the association between diabetes and risk of cardiovascular disease, cancer, and all-cause and cause-specific mortality: a systematic review and meta-analysis of 5,162,654 participants.BMC Med2019;17:136

[40] Edwards FH,Grover FL,Hartz RS.Impact of gender on coronary bypass operative mortality.Ann Thorac Surg1998;66:125-31

[41] Clayton TC,Henderson RA.Do men benefit more than women from an interventional strategy in patients with unstable angina or non-ST-elevation myocardial infarction? The impact of gender in the RITA 3 trial.Eur Heart J2004;25:1641-50

[42] Attia T,Houghtaling PL,Sabik EM.Does a similar procedure result in similar survival for women and men undergoing isolated coronary artery bypass grafting?.J Thorac Cardiovasc Surg2017;153:571-579.e9

[43] Sandoval Y,Canoniero M,Garcia S.Complete versus incomplete coronary revascularization of patients with multivessel coronary artery disease.Curr Treat Options Cardiovasc Med2015;17:366

[44] den Ruijter HM, Haitjema S, van der Meer MG, et al.; IMAGINE Investigators. Long-term outcome in men and women after CABG; results from the IMAGINE trial.Atherosclerosis2015;241:284-8

[45] Oertelt-Prigione S,Kaltenbach M,Regitz-Zagrosek V.Detection of gender differences in incomplete revascularization after coronary artery bypass surgery varies with classification technique.Biomed Res Int2013;2013:108475 PMCID:PMC3722773

[46] Burgess SN,Nguyen TL.Comparison of late cardiac death and myocardial infarction rates in women vs men with ST-elevation myocardial infarction.Am J Cardiol2020;128:120-6

[47] Koch CG.Gender and cardiac surgery.Anesthesiol Clin North Am2003;21:675-89

[48] Lawton JS,Bailey MS.Radial artery grafts in women: utilization and results.Ann Thorac Surg2005;80:559-63

[49] Jabagi H,Hessian R,Rubens FD.Impact of gender on arterial revascularization strategies for coronary artery bypass grafting.Ann Thorac Surg2018;105:62-8

[50] Dixon LK,Di Tommaso E.Females have an increased risk of short-term mortality after cardiac surgery compared to males: Insights from a national database.J Card Surg2022;37:3507-19

[51] Loop FD,Cosgrove DM.Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.N Engl J Med1986;314:1-6

[52] Gaudino M,Alexander JH.Sex differences in outcomes after coronary artery bypass grafting: a pooled analysis of individual patient data.Eur Heart J2021;43:18-28 PMCID:PMC8851663

[53] Lamin V,Jakobczak R.Mechanisms responsible for serotonin vascular reactivity sex differences in the internal mammary artery.J Am Heart Assoc2018;7

[54] Tatoulis J,Buxton BF.The radial artery in coronary surgery: a 5-year experience--clinical and angiographic results.Ann Thorac Surg2002;73:143-7; discussion 147

[55] Dimitrova KR,Geller CM.Radial artery grafting in women improves 15-year survival.J Thorac Cardiovasc Surg2013;146:1467-73

[56] Khot UN,Pettersson G,Li J.Radial artery bypass grafts have an increased occurrence of angiographically severe stenosis and occlusion compared with left internal mammary arteries and saphenous vein grafts.Circulation2004;109:2086-91

[57] Kim SG,Mintz GS.The importance of gender on coronary artery size: in-vivo assessment by intravascular ultrasound.Clin Cardiol2004;27:291-4

[58] Hess CN,Gibson CM.Saphenous vein graft failure after coronary artery bypass surgery: insights from PREVENT IV.Circulation2014;130:1445-51

[59] Gharibeh L,Ouimet M.Conduits’ biology regulates the outcomes of coronary artery bypass grafting.JACC Basic Transl Sci2021;6:388-96 PMCID:PMC8093468

[60] Desai ND, Naylor CD, Kiss A, et al.; Radial Artery Patency Study Investigators. Impact of patient and target-vessel characteristics on arterial and venous bypass graft patency: insight from a randomized trial.Circulation2007;115:684-91

[61] Edwards FH, Ferraris VA, Shahian DM, et al.; Society of Thoracic Surgeons. Gender-specific practice guidelines for coronary artery bypass surgery: perioperative management.Ann Thorac Surg2005;79:2189-94

[62] Attaran S,Ashrafian H.Off-pump versus on-pump revascularization in females: a meta-analysis of observational studies.Perfusion2014;29:385-96

[63] ter Woorst JF, Hoff AHT, Haanschoten MC, Houterman S, van Straten AHM, Soliman-Hamad MA. Do women benefit more than men from off-pump coronary artery bypass grafting?.Neth Heart J2019;27:629-35 PMCID:PMC6890870

[64] Faerber G, Zacher M, Reents W, et al.; GOPCABE investigators. Female sex is not a risk factor for post procedural mortality in coronary bypass surgery in the elderly: a secondary analysis of the GOPCABE trial.PLoS One2017;12:e0184038 PMCID:PMC5576733

[65] Puskas JD,Taggart DP.Experience is crucial in off-pump coronary artery bypass grafting.Circulation2019;139:1872-5

[66] Anwar A,Radhakrishnan RM.Long-term outcomes of women compared to men after off-pump coronary artery bypass grafting-a propensity-matched analysis.Indian J Thorac Cardiovasc Surg2025;41:126-38

[67] Nathoe HM, Moons KG, van Dijk D, et al.; Octopus Study Group. Risk and determinants of myocardial injury during off-pump coronary artery bypass grafting.Am J Cardiol2006;97:1482-6

[68] Lopes CT,Brunori EH,Lopes Jde L.Excessive bleeding predictors after cardiac surgery in adults: integrative review.J Clin Nurs2015;24:3046-62

[69] Shehata N,Alghamdi AA.Risk factors for red cell transfusion in adults undergoing coronary artery bypass surgery: a systematic review.Vox Sang2007;93:1-11

[70] Wang E,Hu S.Impact of gender differences on hemostasis in patients after coronary artery bypass grafts surgeries in the context of tranexamic acid administration.J Cardiothorac Surg2022;17:123 PMCID:PMC9123662

[71] Kim C,Pavlic T.A systematic review of gender differences in mortality after coronary artery bypass graft surgery and percutaneous coronary interventions.Clin Cardiol2007;30:491-5 PMCID:PMC6653288

[72] Dalén M,Ivert T,Sartipy U.Coronary artery bypass grafting in women 50 years or younger.J Am Heart Assoc2019;8:e013211 PMCID:PMC6818006

[73] Vaccarino V,Kasl SV.Gender differences in recovery after coronary artery bypass surgery.J Am Coll Cardiol2003;41:307-14

[74] Koch CG,Cywinski JB.Health-related quality of life after coronary artery bypass grafting: a gender analysis using the Duke Activity Status Index.J Thorac Cardiovasc Surg2004;128:284-95

[75] Stanicki P,Wieteska M,Milanowska J.Postoperative depression in patients after coronary artery bypass grafting (CABG) - a review of the literature.Pol Przegl Chir2020;92:32-8

[76] Korbmacher B,Dalyanoglu H.Perioperative and long-term development of anxiety and depression in CABG patients.Thorac Cardiovasc Surg2013;61:676-81

[77] Geulayov G,Dankner D.Symptoms of depression and anxiety and 11-year all-cause mortality in men and women undergoing coronary artery bypass graft (CABG) surgery.J Psychosom Res2018;105:106-14

[78] Smith JR,Bonikowske AR,Olson TP.Sex differences in cardiac rehabilitation outcomes.Circ Res2022;130:552-65 PMCID:PMC8868533

[79] Feola M,Daniele B.Gender differences in the efficacy of cardiovascular rehabilitation in patients after cardiac surgery procedures.J Geriatr Cardiol2015;12:575-9

[80] Li S,Mukamal K.Sex and racial disparities in cardiac rehabilitation referral at hospital discharge and gaps in long-term mortality.J Am Heart Assoc2018;7:e008088