Disparities in therapies for coronary artery disease with reduced left ventricular ejection fraction
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Abstract
Revascularization through percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is used to manage left ventricular systolic dysfunction (LVSD) due to coronary artery disease (CAD). This review provides an overview of coronary revascularization for CAD with reduced left ventricular ejection fraction (LVEF), focusing on disparities in management. CABG provides more complete revascularization, and lower long-term all-cause mortality and reintervention and MI rates compared to PCI in patients with LVSD and CAD. Consequently, CABG is recommended as the primary revascularization therapy for CAD with reduced LVEF, with PCI being reserved for patients who are high-risk or have unfavorable coronary anatomy. Although LVSD increases revascularization risk, differential outcomes can be attributed to patients’ biological, behavioral, and socioeconomic factors as well as health system deficiencies. Women and racially and/or ethnically minoritized patients often present with progressive disease and greater comorbidity, experience delays in diagnosis and treatment, and have higher morbidity and mortality rates post-revascularization. These disparities may be explained by biological differences compounded by social determinants of health. Patients with CAD with LVSD pose unique medical challenges, which may be further complicated by disparities in care. Increased representation of minoritized patients in cardiovascular trials is needed to elucidate these differences and their long-term impact.
Keywords
INTRODUCTION
Coronary artery disease (CAD) is the world’s leading cause of death due to myocardial infarction, heart failure, and/or sudden death[1,2]. Approximately 125 million people live with CAD worldwide[3]. Risk factors for atherosclerotic CAD notably include smoking, diabetes mellitus, dyslipidemia, hypertension, obesity, and stress[1]. CAD may be asymptomatic or present with minimal symptoms but frequently presents as unstable angina, non-ST-elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI)[1]. CAD may progress to heart failure, usually presenting as shortness of breath, fatigue, and/or fluid overload[4].
Factors generally associated with developing heart failure include older age, male sex, hypertension, diabetes mellitus, CAD, previous myocardial infarction (MI), and valvular heart disease[4]. In adults between the ages of 45 and 95, the lifetime risk of developing heart failure ranges between 20% and 45%. It is estimated that 6.5 million people in the United States are affected by heart failure, with almost 1 million hospitalizations each year[4] and a financial toll of more than 40 billion U.S. dollars[5,6].
Ischemic cardiomyopathy (ICM) refers to systolic left ventricular systolic dysfunction (LVSD) that is primarily due to CAD. Patients with ICM can present with no, minimal, or advanced symptoms of heart failure[3]. ICM accounts for almost half of all heart failure cases[7,8]. It is often due to a mix of irreversible loss of viable myocardium and regions of stunned but viable myocardium[9]. The treatment of ischemic LVSD involves either optimal medical therapy or revascularization in the form of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Treatment decisions are usually based on multiple factors, including but not limited to age, sex, type of disease, and comorbidities. While disparities exist for both CABG and PCI, this review will primarily focus on the growing body of evidence highlighting disparities pertaining to CABG, considering the comparatively smaller body of research on PCI disparities in this specific patient population, who are commonly scheduled for surgical care or conservatively managed with optimal medical therapy.
Burdens particularly affect patients from minoritized and marginalized communities. For example, variations in the prevalence of HF exist, mostly due to differences in sex, race, and/or ethnicity. In White men, this ranges between 30% and 42%, White women 32% and 39%, Black men 20% and 29%, and Black women 24% and 46%[10]. Presentations may also vary, as Black and White men most commonly have heart failure with reduced ejection fraction (HFrEF), while White women more commonly develop heart failure with preserved ejection fraction (HFpEF)[10]. Non-White patients are more likely to suffer from and require hospitalization for heart failure than White patients, yet have lower utilization of ventricular assist devices and heart transplantation, suggesting structural barriers in care[11,12]. Meanwhile, women present with unique forms of heart failure distinct from men, yet clinical trials and guidelines are based on predominantly male patient populations, thereby poorly meeting the needs of diverse populations[13]. In this review article, we present an overview of CAD with reduced left ventricular ejection fraction (LVEF) and tackle the disparities in the management of patients due to differences in race, ethnicity, sex, gender, and other possible factors [Figure 1].
Figure 1. Disparities in CAD with reduced LVEF. CABG: Coronary artery bypass grafting; CAD: coronary arterydisease; LVEF: left ventricular ejection fraction; PCI: percutaneous coronary intervention; SES: socioeconomic status.
TREATMENT OF CAD WITH REDUCED LVEF
The Surgical Treatment for Ischemic Heart Failure (STICH, NCT00023595) trial[14] and its extended follow-up study (STICHES)[15] provided the most comprehensive insights into revascularization of CAD with LVSD. Comparing medical therapy plus CABG (n = 610) to medical therapy alone (n = 602), the risk of all-cause mortality at a median follow-up of 56 months was comparable between groups (HR 0.86
Less invasive surgical approaches may present further opportunities for patient-centered care by reducing procedural invasiveness. For example, off-pump CABG (OPCAB) may be associated with comparable outcomes and rates of complete revascularization compared to conventional CABG, although evidence in this patient population is limited to smaller studies and mostly single-center experiences with limited follow-up[23]. Simultaneously, improvements in PCI techniques have resulted in improved outcomes over time. The SYNTAX II trial (NCT02015832) compared contemporary vs. historical PCI techniques, finding lower composite rates of all-cause mortality, stroke, myocardial infarction, or repeat revascularization at two years of follow-up for modern vs. older PCI techniques (13.2% vs. 21.9%; P < 0.001)[24]. However, this trial did not enroll patients with reduced LVEF, requiring further study in this patient population.
More recently, the REVIVED-BCIS2 trial (NCT01920048) compared stable patients with LVEF of 35% or less and no history of hospitalization two years prior to enrollment undergoing PCI (n = 347) vs. OMT alone (n = 353)[25]. At a median follow-up of 41 months, the primary composite outcome of all-cause mortality or hospitalization for heart failure was comparable between groups (HR 0.99 [0.78-1.27]). LVEF was similar between the two groups at 6 and 12 months, while quality-of-life scores appeared to initially favor PCI at 6 and 12 months, but there was no significant difference at 24 months. Despite publication before the trial, the most recent 2021 American College of Cardiology (ACC)/American Heart Association (AHA)/Society for Cardiovascular Angiography and Interventions (SCAI) guidelines recommendations reflect the findings from the REVIVED-BCIS and STICH(ES) trials [Table 1].
| Guidelines | Setting | Recommendation for CABG vs. PCI in CAD with LVSD | COR | LOE |
| AHA/ACC/ACCP/ASPC/NLA/PCNA - chronic CAD, 2023[26] | PCI vs. CABG in chronic CAD | In patients with chronic coronary disease (CCD) who have significant left main disease or multivessel disease with severe LVSD (LVEF ≤ 35%), CABG, in addition to GDMT, is recommended over medical therapy alone to improve survival | 1 | B-R |
| In patients with CCD and multivessel disease with severe LVSD, CABG added to GDMT is of intermediate economic value compared with medical therapy alone | Cost value statement: intermediate value | B-NR | ||
| AHA/ACC/HFSA - heart failure, 2022[27] | Revascularization for CAD in HF | In selected patients with HF with reduced EF (EF ≤ 35%), and suitable coronary anatomy, surgical revascularization plus GDMT is beneficial in improving symptoms, cardiovascular hospitalizations, and long-term all-cause mortality | 1 | B-R |
| ACC/AHA/S CAI - revascularization, 2021[28] | Revascularization to improve survival in symptomatic ischemic heart disease (SIHD) compared with medical therapy | In patients with SIHD and multivessel CAD appropriate for CABG with severe LVSD (LVEF < 35%), CABG is recommended to improve survival | 1 | B-R |
| In selected patients with SIHD and multivessel CAD appropriate for CABG and mild-to-moderate LVSD (LVEF 35%-50%), CABG (to include a left internal mammary artery graft to the LAD) is reasonable to improve survival | 2a | B-NR | ||
| ESC - heart failure, 2021[29] | Myocardial revascularization in patients with heart failure with reduced ejection fraction | CABG should be considered as the first-choice revascularization strategy in patients suitable for surgery, especially if they have diabetes and for those with multivessel disease | 2a | B |
| PCI may be considered as an alternative to CABG based on Heart Team evaluation considering coronary anatomy, comorbidities, and surgical risk | 2a | C | ||
| CCS/CHF - Heart Failure, 2021[30] | New pharmacologic standard of care for heart failure with reduced ejection fraction | No recommendations on PCI vs. CABG | N/A | N/A |
| ESC/EACTS- revascularization, 2018[31] | Revascularizations in patients with chronic heart failure and systolic left ventricular dysfunction (ejection fraction < 35%) | In patients with severe LVSD and coronary artery disease suitable for intervention, myocardial revascularization is recommended | 1 | B |
| CABG is recommended as the first revascularization strategy choice for patients with multivessel disease and acceptable surgical risk | 1 | B | ||
| In patients with one- or two-vessel disease, PCI should be considered an alternative to CABG when complete revascularization can be achieved | 2a | C | ||
| In patients with three-vessel disease, PCI should be considered based on the evaluation by the Heart Team of the patient’s coronary anatomy, the expected completeness of revascularization, diabetes status, and comorbidities | ||||
| CCS - Heart Failure, 2017[32] | Heart failure - revascularization and CAD | We recommend consideration of coronary artery bypass surgery for patients with chronic ICM, LVEF < 35%, graftable coronary arteries, and who are otherwise suitable candidates for surgery, irrespective of the presence of angina and HF symptoms, to improve mortality, repeat hospitalization, and quality of life | Strong | Moderate |
| We suggest consideration of PCI for patients with HF and limiting symptoms of cardiac ischemia, and for whom coronary artery bypass grafting (CABG) is not considered appropriate | Weak | Low |
While the role of PCI is not described in detail in the American guidelines, European and Canadian guidelines recommend that PCI may be considered as an alternative revascularization modality in patients with high surgical risk or the presence of one- or two-vessel disease with the potential for complete revascularization[33]. In recent years, advances in PCI, such as later-generation drug-eluting stents, intra-coronary imaging, radial access, physiology-guided PCI, bifurcation techniques, and advances in chronic total occlusion recanalization, have resulted in improved short- and long-term outcomes, and may explain why PCI rates in this patient population have grown over time despite existing trial evidence[34]. These improvements in techniques and outcomes require direct comparison with CABG[33]. Nevertheless, contemporary trials directly comparing PCI and CABG often exclude patients with (very) reduced LVEF, such as in the case of FAME 3 Trial (NCT02100722), where only patients with LVEF > 30% were included[35]. The upcoming STICH3.0 International Consortium (NCT05427370) will provide contemporary insights into the comparative effectiveness of CABG and PCI to manage patients with CAD and LV dysfunction[33,36]. Meanwhile, the Revascularization Choices Among UnderRepresented Groups Evaluation (RECHARGE):Women and RECHARGE:Minorities aim to specifically investigate PCI vs. CABG in populations that are underrepresented in existing revascularization trials[37]. Even with increasing research into the nuances of different patient populations, there are limitations to applying trial-derived recommendations to real-world scenarios. Clinical trials abide by strict eligibility criteria that challenge the generalizability of their findings, with half to three-quarters of all real-world patients meeting clinical criteria that would make them ineligible for enrolment in contemporary trials[38,39]. This is one of many benefits of a Heart Team approach, as it interprets multidisciplinary evidence in the context of the patient’s unique clinical profile to facilitate shared decision-making and personalized care[40]. However, even with the increasing adoption of Heart Teams, some disparities in clinical outcomes persist.
SURGICAL CONSIDERATIONS IN CAD WITH REDUCED LVEF [Figure 2]
Diagnosis
Initial investigations of reduced LVEF should distinguish isolated ICM from non-ischemic cardiomyopathy. Mixed cardiomyopathy is suspected if the extent of CAD on coronary angiography is disproportionate to the clinical picture or symptom severity. In patients who are minimally symptomatic, inducible ischemia is identified with stress testing. Viability assessment clarifies the benefit of revascularization through late gadolinium enhancement-cardiac magnetic resonance (LGE-CMR) imaging to assess the scar burden and F-18-fluorodeoxy glucose positron emission tomography to rule out systemic inflammatory disease[41]. Greater than 50% transmural scar involvement on LGE-CMR predicts poor regional recovery after revascularization[42]; however, this understanding has been challenged in other studies[43], with the STICH trial not demonstrating the ability of viability testing to predict survival benefit from CABG[44]. The presence of dense scar formation often cinches the decision against operative revascularization in patients who are already high-risk.
In the clinical setting, CMR has greater utility in women for quantification of ventricular size and function since transthoracic echo image quality can be compromised by breast tissue attenuation. As outlined by the AHA 2014 consensus statement on the role of non-invasive testing in women, stress CMR is a reasonable index diagnostic test in symptomatic women with intermediate-high risk of CAD and resting ST-segment abnormalities or exercise intolerance[45,46]. In pre-menopausal women with functional disability, stress CMR may also be appropriate for the identification of obstructive CAD and prognostication[45].
Figure 2. Considerations for the Management of CAD with reduced LVEF. CABG: Coronary artery bypass grafting; CMR: cardiac magneticresonance; GDMT: guideline-directed medical therapy; ICD: implantable cardioverter-defibrillator; IMR: ischemic mitral regurgitation; MV: mitral valve; TTE: transthoracic echocardiography.
Operative management
Beyond the revascularization strategy, there are several operative considerations for patients with LVSD. Multiple arterial grafting (MAG) may offer superior conduit patency with the surgeons’ expertise and preference determining the choice of an on-pump or off-pump strategy[3]; however, routine use of MAG is cautioned in ICM for a few reasons. Firstly, perioperative administration of high-dose vasopressors predisposes arterial grafts to spasm[47]. Secondly, the initial flow of arterial grafts is less than that of vein grafts due to smaller luminal diameter, thus posing the risk of early coronary hypoperfusion[48]. Further, arterial grafts may be of insufficient length for direct aortocoronary bypass in dilated hearts, and can only be used in composite or sequential grafting, techniques that are often deferred to dedicated coronary surgeons. Lastly, the complexity and additional operative time of performing MAG may be poorly tolerated in severe LVSD. There is also the argument that patients with very low LVEF do not receive the long-term benefit of MAG and should be spared from its associated risks[49,50]. Evidence also suggests that epicardial lead placement is beneficial and should be considered in patients undergoing concomitant surgery with
Despite its potential benefits, MAG remains underutilized among women. In the Society of Thoracic Surgeon (STS) database from 2011-2019, women were significantly less likely to receive left internal thoracic artery, bilateral internal thoracic artery (BITA), or radial grafts[51]. Rate of increasing BITA use is higher in men, and although propensity score matching removed significant differences in BITA and radial artery graft use between men and women, there was still greater use of ≥ three artery MAG in men than women (10.5% vs. 7.3%; P = 0.048)[52]. Hesitancy towards performing MAG in women can be a result of small target vessel and arterial conduit size, risk of sternal dehiscence with BITA, and higher preoperative risk profile[53]. Women are known to have worse early[54] and late mortality, and greater risk of postoperative major adverse cardiac and cerebrovascular events post-CABG than men[55]. In a New York State registry study, MAG is associated with improved survival and a lower rate of major adverse cardiac events among low-risk patients regardless of sex. This was not seen among high-risk patients, with different risk thresholds between sexes when the benefit of MAG is lost[56]. In addition, a propensity-matched analysis between MAG vs. single arterial grafting revealed lower seven-year mortality in men who received MAG (HR 0.80 [0.73-0.87]), but not for women (HR 0.99 [0.84-1.15])[56]. The upcoming ROMA:Women trial (NCT03217006) will explore the role of MAG in women; however, the joint impact of sex and LVSD remains to be established as patients with LVEF ≤ 35% will be excluded[57].
Within surgical revascularization, women appear to derive disproportionately greater benefit from off-pump CABG (OPCAB) than men for rates of postoperative death, stroke, and major cardiac events[58]. Adding the additional context of LVSD, OPCAB in the modern era has been associated with comparable, if not better, early survival than on-pump CABG[59], with potentially higher five-year mortality, potentially due to suboptimal longitudinal management rather than surgical strategy[60]. The merit of OPCAB in women with reduced LVEF remains to be explored.
Other operative considerations include addressing moderate-severe ischemic mitral regurgitation at the time of CABG through mitral repair or replacement[61,62], concomitant tricuspid valve repair for moderate-severe tricuspid regurgitation[63], and arrhythmia surgery for atrial fibrillation (AF) for restoration of atrial kick to complement CABG in LVEF recovery[64]. Women have worse age-standardized mortality after combined CABG/mitral valve surgery compared to men[65].
A 90-day waiting period post-revascularization is recommended before proceeding with primary prevention implantable cardioverter-defibrillator (ICD) implantation in patients who have LVEF ≤ 35% despite guideline-directed medical therapy (GDMT)[66]. In a multinational European registry study on primary prevention ICD, fewer women than men undergo ICD implantation; however, women also have lower mortality and receive fewer appropriate ICD shocks after multivariate adjustment[67]. In a race-based subanalysis of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT, NCT00000609) on primary prevention ICD for LVEF ≤ 35% in ICM and non-ischemic cardiomyopathy, survival benefits conferred by ICD was independent of race[68]. Furthermore, the incidence of ICD refusal and medication non-compliance were comparable between Black and Caucasian patients[68], suggesting that the lower rates of specialist consultation and ICD implantation in eligible patients who do not identify as White may be attributed to biases in health care delivery[69].
After revascularization, routine statin and anti-platelet therapies prevent cardiovascular disease progression[70]. Further anticoagulation may be desired for LV thrombus, AF, and after surgical ventricular restoration[3]. HFrEF is managed with foundational quadruple medical therapy of angiotensin-converting enzyme inhibitor, angiotensin type II receptor blocker, or preferentially angiotensin receptor neprilysin inhibitor; beta-blocker; mineralocorticoid receptor antagonist; and sodium-glucose co-transporter 2 inhibitor[71]. Despite a similar predominance of White men in the enrollment of landmark heart failure trials, equivalent GDMT efficacy in women and men has been shown through meta-analysis[72]. Underprescription of GDMT remains an issue, but there may be no significant racial disparity in prescription patterns; in fact, Black patients are more likely to achieve the target dose due to baseline hypertension[73,74]. Patients with poor LVEF recovery are followed closely for chronic issues of cardiorenal syndrome, congestive hepatopathy, pulmonary hypertension, and evaluation of candidacy for advanced heart failure therapies.
DISPARITIES IN MANAGEMENT AND OUTCOMES OF CAD WITH REDUCED LVEF
There is growing evidence pointing to various psychosocioeconomic disparities that impact the prevalence, prognosis, access to care, and outcomes of patients with ICM. Social factors that have been associated with differential prevalence of CAD and resulting outcomes include sex, gender, race, ethnicity, socioeconomic status, social isolation, and stressful lifestyles[75-78].
Women with CAD commonly present with atypical symptoms, such as abdominal discomfort and heartburn, nausea or vomiting, and fatigue or dizziness, while women with acute coronary syndrome (ACS) tend to present at an older age with more comorbidities, including obesity, smoking, depression, hypertension, diabetes, and chronic kidney disease, compared to men[79-87]. At hospital presentation, they experience delays in diagnostic testing (duration to ECG: 7.5 min vs. 5.7 min in men)[88], and are less likely to receive evidence-based treatment, including dual antiplatelet therapy (89% vs. 93.5%; P < 0.001), heparin (66.7% vs. 71.2%; P < 0.001), or reperfusion therapy with fibrinolysis and/or PCI (50.2% vs. 59.5%; P < 0.001). Women also experience higher in-hospitality mortality rates than men, even after adjusting for age and clinical variables (adjusted OR 1.20 [1.01-1.43])[89]. According to the Framingham Heart Study, despite women being associated with fewer diagnoses of obstructive CAD (≥ 50% stenosis), women with obstructive CAD are at higher risk for 30-day (RR 1.75 [1.48-2.07]) mortality compared to men[90]. They are also at a greater risk of developing symptomatic heart failure without an antecedent MI (RR 11.4% [9.6%-13.2%]) for men and 15.4% [13.5%-17.3%] for women)[87,90]. The incidence of CAD rises in menopausal/post-menopausal compared to pre-menopausal women (age 45-54 years: OR 2.5; P < 0.01)[91].
The incidence of CAD per 1,000-person years is impacted by patients’ race, gender, and comorbidities: Black women 5.1% [4.2-6.2], Black men 10.6% [8.9-12.7], White women 4.0% [3.5-4.6], and White men 12.5% [11.5-13.7][92]. Hypertension is significantly associated with CAD in Black women (HR 4.8 [2.5-9.0]), while diabetes mellitus is predictive among White women (HR 3.3 [2.4-4.6])[92]. Further, racial and/or ethnic minority patients present with ACS at a younger age (66 years vs. 73 years old; P < 0.001) with multiple comorbidities including hypertension (66% vs. 54%; P < 0.001), hypercholesterolemia (49% vs. 34%;
Over the past few decades, there have been persistent, albeit declining, disparities in the utilization of revascularization among women and racial and/or ethnic minority patients. This applies to both patients with and without reduced LVEF[93,102,103]. Women present for revascularization at an older age with higher comorbidity profiles[52]. Women also experience delays in revascularization from symptom onset compared to men (14.4 h vs. 7.2 h)[88]. Following CABG, women have higher major adverse cardiac and cerebrovascular events, with a higher incidence of MI and repeat revascularization compared to men[104]. These differences persist despite off-pump surgery and MAG[104]. Overall, women have higher mortality following CABG compared to men even after risk adjustment (65% and 31% at 10 and 20 years, respectively, vs. 74% and 41%; P ≤ 0.0001)[105]. With regards to PCI, women have higher major adverse cardiac events
Additionally, non-White patients requiring revascularization are likely to present with higher comorbidity burden (hypertension: 69.8% vs. 64.0% and CHF: 25.6% vs. 18.2%) and greater acuity requiring emergency admissions (30.1% vs. 24.6% in White patients), which are associated with higher mortality[107,108]. When they undergo CABG, non-White patients have a 33% higher risk-adjusted mortality rate (4.8% in non-White vs. 3.8% in White patients) compared to White patients (OR, 1.33 [1.23-1.45]) that were only partially explained by socioeconomic status or hospital quality (adjusted OR 1.16 [1.05-1.27])[75,107,109]. Assessing the intersection of racial and sex-based disparities, Black women experience the highest in-hospital mortality, followed by Asian women, White women, Black men, and Hispanic women compared to White men using logistic regression after controlling for covariates (P < 0.001)[110]. Black patients also experience longer hospital stays and higher rates of surgical site infections, sepsis, stroke, and pneumonia following CABG[108]. Following PCI, Black patients have a higher risk of readmission, with 90 days of discharge (adjusted OR 1.62 [1.32-2.00]) and cumulative mortality compared to White patients (adjusted HR 1.45 [1.30-1.61])[111]. Indigenous patients in the United States experience greater in-hospital and long-term mortality rates following CABG compared to White (OR 3.8 [1.5-9.8]), African American (OR 3.4 [1.1-9.9]), Hispanic
Causes of disparities in CAD with reduced LVEF
The etiology of these disparities, whether genetic in origin (i.e., “nature”) or attributable to non-physiological factors such as culture, lifestyle, and environment (i.e., “nurture”), has led to great debate and remains to be clarified[115]. Studies suggest multiple interrelated causes.
In terms of biological predisposition, particularly at an older age, there is evidence that women lose the cardioprotective benefits of estrogen following menopause[116]. Additionally, early menopause, pregnancy-associated conditions, such as gestational hypertension, gestational diabetes, preeclampsia and eclampsia, and maternal autoimmune disease, all increase the risk of premature CAD in women[117,118]. In addition, studies suggest differential pathophysiology of CAD in White vs. Black patients[78]. CAD in Black patients may be manifested by small-vessel disease resulting in chronically increased oxygen demand, while it is related to greater epicardial vessel atherosclerosis and acutely decreased oxygen supply in White patients[78]. With regards to revascularization, Asian patients may have coronary arteries that are smaller in diameter than those in White patients, leading to more challenging CABG procedures[119]. Moreover, Asian individuals have a unique antiplatelet feature, also known as the “East Asian paradox”, with patients suffering from higher bleeding rates and lower ischemic events after undergoing PCI[120]. However, further research is needed to elucidate whether these physiological differences are predominantly mediated by environmental, social, or genetic factors.
From a “nurture” perspective, many social factors may compound to impact patients’ access to care and outcomes. Health literacy, particularly as it pertains to cardiovascular disease, tends to be lower among women, lower socioeconomic, and racial and/or ethnic minority patients[121,122]. The prolonged ischemic duration among women with ACS has been historically associated with decreased symptom recognition by patients and providers[121,123]. From the care delivery perspective, young women with CAD are less likely to be asked about their cardiovascular risk factors[124] or receive counseling on risk modification[125]. Additionally, patients from racially and/or ethnically minoritized groups may experience systemic racism that predisposes them to worse outcomes. Following an acute myocardial infarction, Black patients experience greater case fatality rates than White patients living in low- and medium-income areas, suggesting compiling social factors that underlie social disparities in outcomes[126]. Despite having a greater comorbidity burden, racially and/or ethnically minoritized groups are more likely to have lower socioeconomic means, leading them to present to low-volume and/or low-quality facilities in the United States[77,107,108,112]. Racial and/or ethnic disparities in revascularization may be explained by racial segregation, referral patterns, and geographic proximity to cardiac centers[107,127]. Therefore, multilevel systemic interventions targeting healthcare providers and vulnerable communities are needed to promote health literacy, identify high-risk patients, and provide them with comprehensive cardiovascular care.
KNOWLEDGE GAPS AND WAYS FORWARD
Despite the poorer outcomes observed among women and racialized and/or minoritized patients, they have been historically underrepresented in cardiovascular trials, further exacerbating the gaps in care[128,129]. This may be the result of mistrust in healthcare, historical discrimination, insufficient diversity of research leadership, and related social factors such as socioeconomic status, geographical location, education, and health literacy[107,128,130]. Promoting diverse representation in clinical trial leadership and trial participants is the first step in identifying and addressing gaps in cardiovascular care delivery. There is a need to address the barriers and causes of underrepresentation and variable enrollment of different populations in cardiovascular trials[129]. Moreover, further investigation is warranted to determine to what extent the observed differences in outcomes are the result of genetic factors, risk factors, sociodemographic factors, and systemic factors. For instance, the regionality of atherosclerosis may differ across different ethnicities, which can contribute to observed differences in outcomes[130]. Lastly, intersectionality in disease burdens[126], access to care, and outcomes after care must be recognized to reflect patients’ unique intersecting identities, whereas differential patient preferences and needs must be respected. In response, the National Institute of Health Revitalization Act of 1993 established “policy and guidelines for the inclusion of women and minorities as subjects in clinical research”, with its 2017 update adding the requirement for Phase III clinical trials to submit results of sex/gender, race, and/or ethnicity analysis to Clinicaltrials.gov[131]. To optimize treatment for our diverse patient populations, further research, increased inclusion, improved patient engagement, and more honest reflection are necessary.
Furthermore, patients’ broader social determinants of health must be properly recognized to ensure adherence to OMT, long-term follow-up, and lifestyle changes, each of which has been negatively associated with low socioeconomic status, low health literacy, and other determinants after both PCI and CABG[132,133]. In addition, biases in care must be evaluated and addressed, as women and patients of low socioeconomic status observe lower rates of multiple arterial grafting[132-134]. Unconscious bias training may reduce differential practices between patient populations that are not fully guided by clinical indications[135]. Simultaneously, engaging patients and communities through community-based participatory research and patient-centered outcomes can strengthen the physician-patient relationship, highlight gaps in care that may be bridged, and promote shared decision-making[136,137]. These efforts should be rooted in the context and culture of the local community as patient preferences and community values may vary considerably by country and population.
CONCLUSION
CAD with LVSD poses unique challenges. Current guidelines are based on limited randomized and observational evidence for LVSD, requiring direct trial evidence comparing CABG and PCI in patients with LVSD. Ongoing trials, such as the STICH3C trial (NCT05427370) and the broader STICH3.0 International Consortium, will shed further light on the management of this complex patient population. In addition, further work is needed to elucidate and address disparities in access to and outcomes after coronary revascularization, which will require the engagement of multidisciplinary Heart Teams, primary care physicians, researchers, and patients.
DECLARATIONS
Authors’ contributions
Writing the manuscript; performed the literature search and review; made substantial contributions to the conception, design, and edition of the manuscript: Ghunaim AH, Vervoott D, Elfaki LA, Deng MX, Marquis-Gravel G, Fremes SE
Prepared the figures and tables: Ghunaim AH, Vervoott D, Elfaki LA, Deng MX
Availability of data and materials
Not applicable.
Financial support and sponsorship
This manuscript is supported in part by the Canadian Institutes of Health Research (CIHR) grant #471008. DV is supported by the CIHR Vanier Canada Graduate Scholarship for work outside this manuscript.
Conflicts of interest
All authors declared that there are no conflicts of interest.
Ethical approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Copyright
© The Author(s) 2023.
REFERENCES
1. Malakar AK, Choudhury D, Halder B, Paul P, Uddin A, Chakraborty S. A review on coronary artery disease, its risk factors, and therapeutics. J Cell Physiol 2019;234:16812-23.
2. Bollano E, Redfors B, Rawshani A, et al. Temporal trends in characteristics and outcome of heart failure patients with and without significant coronary artery disease. ESC Heart Fail 2022;9:1812-22.
3. Bakaeen FG, Gaudino M, Whitman G, et al. 2021: The American Association for thoracic surgery expert consensus document: coronary artery bypass grafting in patients with ischemic cardiomyopathy and heart failure. J Thorac Cardiovasc Surg 2021;162:829-50.e1.
4. Murphy SP, Ibrahim NE, Januzzi JL Jr. Heart failure with reduced ejection fraction: a review. JAMA 2020;324:488-504.
5. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail 2013;6:606-19.
6. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;128:e240-327.
7. Maggioni AP, Dahlström U, Filippatos G, et al. EURObservational research programme: regional differences and 1-year follow-up results of the heart failure pilot survey (ESC-HF pilot). Eur J Heart Fail 2013;15:808-17.
8. Fox KF, Cowie MR, Wood DA, et al. Coronary artery disease as the cause of incident heart failure in the population. Eur Heart J 2001;22:228-36.
9. Del Buono MG, Moroni F, Montone RA, Azzalini L, Sanna T, Abbate A. Ischemic cardiomyopathy and heart failure after acute myocardial infarction. Curr Cardiol Rep 2022;24:1505-15.
10. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 update: a report from the american heart association. Circulation 2022;145:e153-639.
11. Lewsey SC, Breathett K. Racial and ethnic disparities in heart failure: current state and future directions. Curr Opin Cardiol 2021;36:320-8.
12. Cascino TM, Colvin MM, Lanfear DE, et al. Racial inequities in access to ventricular assist device and transplant persist after consideration for preferences for care: a report from the REVIVAL study. Circ Heart Fail 2023;16:e009745.
13. Lam CSP, Arnott C, Beale AL, et al. Sex differences in heart failure. Eur Heart J 2019;40:3859-68c.
14. Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011;364:1607-16.
15. Velazquez EJ, Lee KL, Jones RH, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med 2016;374:1511-20.
16. Carson P, Wertheimer J, Miller A, et al. The STICH trial (surgical treatment for ischemic heart failure): mode-of-death results. JACC Heart Fail 2013;1:400-8.
17. Kim HM, Hwang IC, Choi W, Yoon YE, Cho GY. Combined effects of ARNI and SGLT2 inhibitors in diabetic patients with heart failure with reduced ejection fraction. Sci Rep 2021;11:22342.
18. Lim AH, Abdul Rahim N, Zhao J, Cheung SYA, Lin YW. Cost effectiveness analyses of pharmacological treatments in heart failure. Front Pharmacol 2022;13:919974.
19. Völz S, Redfors B, Angerås O, et al. Long-term mortality in patients with ischaemic heart failure revascularized with coronary artery bypass grafting or percutaneous coronary intervention: insights from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur Heart J 2021;42:2657-64.
20. Sun LY, Gaudino M, Chen RJ, Bader Eddeen A, Ruel M. Long-term outcomes in patients with severely reduced left ventricular ejection fraction undergoing percutaneous coronary intervention vs coronary artery bypass grafting. JAMA Cardiol 2020;5:631-41.
21. Bangalore S, Guo Y, Samadashvili Z, Blecker S, Hannan EL. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation 2016;133:2132-40.
22. Wolff G, Dimitroulis D, Andreotti F, et al. Survival benefits of invasive versus conservative strategies in heart failure in patients with reduced ejection fraction and coronary artery disease: a meta-analysis. Circ Heart Fail 2017;10:e003255.
23. Neumann A, Serna-Higuita L, Detzel H, et al. Off-pump coronary artery bypass grafting for patients with severely reduced ventricular function-A justified strategy? J Card Surg 2022;37:7-17.
24. Serruys PW, Kogame N, Katagiri Y, et al. Clinical outcomes of state-of-the-art percutaneous coronary revascularisation in patients with three-vessel disease: two-year follow-up of the SYNTAX II study. EuroIntervention 2019;15:e244-52.
25. Perera D, Clayton T, O'Kane PD, et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N Engl J Med 2022;387:1351-60.
26. Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the management of patients with chronic coronary disease: a report of the american heart association/American college of cardiology joint committee on clinical practice guidelines. J Am Coll Cardiol 2023;82:833-955.
27. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the american college of cardiology/american heart association joint committee on clinical practice guidelines. J Am Coll Cardiol 2022;79:e263-421.
28. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 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. Circulation 2022;145:e4-17.
29. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European society of cardiology (ESC) with the special contribution of the heart failure association (HFA) of the ESC. Eur Heart J 2021;42:3599-726.
30. McDonald M, Virani S, Chan M, et al. CCS/CHFS heart failure guidelines update: defining a new pharmacologic standard of care for heart failure with reduced ejection fraction. Can J Cardiol 2021;37:531-46.
31. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. EuroIntervention 2019;14:1435-534.
32. Ezekowitz JA, O'Meara E, McDonald MA, et al. 2017 comprehensive update of the canadian cardiovascular society guidelines for the management of heart failure. Can J Cardiol 2017;33:1342-433.
33. Vervoort D, Jolicoeur ME, Marquis-Gravel G, Fremes SE. Is the world ready for the STICH 3.0 trial? Curr Opin Cardiol 2022;37:474-80.
34. Parikh PB, Bhatt DL, Bhasin V, et al. Impact of percutaneous coronary intervention on outcomes in patients with heart failure: JACC state-of-the-art review. J Am Coll Cardiol 2021;77:2432-47.
35. Fearon WF, Zimmermann FM, De Bruyne B, et al. Fractional flow reserve-guided PCI as compared with coronary bypass surgery. N Engl J Med 2022;386:128-37.
36. Fremes SE, Marquis-Gravel G, Gaudino MFL, et al. STICH3C: rationale and study protocol. Circ Cardiovasc Interv 2023;16:e012527.
37. Patient-Centered outcomes research institute award will fund RECHARGE trials of PCI versus CABG in women and minority groups. 2023. Available from: https://citoday.com/news/patient-centered-outcomes-research-institute-award-will-fund-recharge-trials-of-pci-versus-cabg-in-women-and-minority-groups [Last accessed on 24 Nov 2023].
38. He J, Morales DR, Guthrie B. Exclusion rates in randomized controlled trials of treatments for physical conditions: a systematic review. Trials 2020;21:228.
39. Tan YY, Papez V, Chang WH, Mueller SH, Denaxas S, Lai AG. Comparing clinical trial population representativeness to real-world populations: an external validity analysis encompassing 43895 trials and 5685738 individuals across 989 unique drugs and 286 conditions in England. Lancet Healthy Longev 2022;3:e674-89.
40. Veronese ET, Pomerantzeff PMA, Jatene FB. Improving the heart team: an interdisciplinary team and integrated practice unit. World J Cardiol 2021;13:650-3.
41. Ryan M, Morgan H, Chiribiri A, Nagel E, Cleland J, Perera D. Myocardial viability testing: all STICHed up, or about to be REVIVED? Eur Heart J 2022;43:118-26.
42. Garcia MJ, Kwong RY, Scherrer-Crosbie M, et al. State of the art: imaging for myocardial viability: a scientific statement from the american heart association. Circ Cardiovasc Imaging 2020;13:e000053.
43. Hwang HY, Yeom SY, Park EA, Lee W, Jang MJ, Kim KB. Serial cardiac magnetic resonance imaging after surgical coronary revascularization for left ventricular dysfunction. J Thorac Cardiovasc Surg 2020;159:1798-805.
44. Panza JA, Ellis AM, Al-Khalidi HR, et al. Myocardial viability and long-term outcomes in ischemic cardiomyopathy. N Engl J Med 2019;381:739-48.
45. Dastidar AG, Baritussio A, De Garate E, et al. Prognostic role of CMR and conventional risk factors in myocardial infarction with nonobstructed coronary arteries. JACC Cardiovasc Imaging 2019;12:1973-82.
46. Mieres JH, Gulati M, Bairey Merz N, et al. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014;130:350-79.
47. He GW, Taggart DP. Spasm in arterial grafts in coronary artery bypass grafting surgery. Ann Thorac Surg 2016;101:1222-9.
48. Silva M, Rong LQ, Naik A, et al. Intraoperative graft flow profiles in coronary artery bypass surgery: a meta-analysis. J Card Surg 2020;35:279-85.
49. Chikwe J, Sun E, Hannan EL, et al. Outcomes of second arterial conduits in patients undergoing multivessel coronary artery bypass graft surgery. J Am Coll Cardiol 2019;74:2238-48.
50. Mohammadi S, Kalavrouziotis D, Cresce G, et al. Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term benefit? Eur J Cardiothorac Surg 2014;46:425-31.
51. Jawitz OK, Lawton JS, Thibault D, et al. Sex differences in coronary artery bypass grafting techniques: a society of thoracic surgeons database analysis. Ann Thorac Surg 2022;113:1979-88.
52. Jabagi H, Tran DT, Hessian R, Glineur D, Rubens FD. Impact of gender on arterial revascularization strategies for coronary artery bypass grafting. Ann Thorac Surg 2018;105:62-8.
53. Nussbaum S, Henry S, Yong CM, Daugherty SL, Mehran R, Poppas A. Sex-specific considerations in the presentation, diagnosis, and management of ischemic heart disease: JACC focus seminar 2/7. J Am Coll Cardiol 2022;79:1398-406.
54. 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:I323-7.
55. Bryce Robinson N, Naik A, Rahouma M, et al. Sex differences in outcomes following coronary artery bypass grafting: a meta-analysis. Interact Cardiovasc Thorac Surg 2021;33:841-7.
56. Gaudino M, Samadashvili Z, Hameed I, Chikwe J, Girardi LN, Hannan EL. Differences in long-term outcomes after coronary artery bypass grafting using single vs multiple arterial grafts and the association with sex. JAMA Cardiol 2020;6:401-9.
57. Comparison of the Outcomes of single vs multiple arterial grafts in women (ROMA:Women). Available from: https://www.clinicaltrials.gov/study/NCT04124120 [Last accessed on 24 Nov 2023].
58. Puskas JD, Kilgo PD, Kutner M, Pusca SV, Lattouf O, Guyton RA. Off-pump techniques disproportionately benefit women and narrow the gender disparity in outcomes after coronary artery bypass surgery. Circulation 2007;116:I192-9.
59. Ueki C, Miyata H, Motomura N, Sakaguchi G, Akimoto T, Takamoto S. Off-pump versus on-pump coronary artery bypass grafting in patients with left ventricular dysfunction. J Thorac Cardiovasc Surg 2016;151:1092-8.
60. Seese L, Sultan I, Wang Y, Navid F, Kilic A. Off-pump coronary artery bypass surgery lacks a longitudinal survival advantage in patients with left ventricular dysfunction. J Cardiac Surg 2020;35:1793-801.
61. Chan KM, Punjabi PP, Flather M, et al. Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the Randomized Ischemic Mitral Evaluation (RIME) trial. Circulation 2012;126:2502-10.
62. Fattouch K, Guccione F, Sampognaro R, et al. POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. J Thorac Cardiovasc Surg 2009;138:278-85.
63. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the american college of cardiology/American heart association joint committee on clinical practice guidelines. Circulation 2021;143:e35-71.
64. Badhwar V, Rankin JS, Damiano RJ Jr, et al. The society of thoracic surgeons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thorac Surg 2017;103:329-41.
65. Johnston A, Mesana TG, Lee DS, Eddeen AB, Sun LY. Sex differences in long-term survival after major cardiac surgery: a population-based cohort study. J Am Heart Assoc 2019;8:e013260.
66. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the American college of cardiology/American heart association task force on clinical practice guidelines, and the heart rhythm society. J Am Coll Cardiol 2019;74:932-87.
67. Sticherling C, Arendacka B, Svendsen JH, et al. Sex differences in outcomes of primary prevention implantable cardioverter-defibrillator therapy: combined registry data from eleven European countries. Europace 2018;20:963-70.
68. Mitchell JE, Hellkamp AS, Mark DB, et al. Outcome in African Americans and other minorities in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Am Heart J 2008;155:501-6.
69. Kiernan K, Dodge SE, Kwaku KF, Jackson LR 2nd, Zeitler EP. Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes. Heart Rhythm O2 2022;3:807-16.
70. Liu T, Zuo R, Wang J, et al. Cardiovascular disease preventive effects of aspirin combined with different statins in the United States general population. Sci Rep 2023;13:4585.
71. Greene SJ, Khan MS. Quadruple medical therapy for heart failure: medications working together to provide the best care. J Am Coll Cardiol 2021;77:1408-11.
72. Wang N, Evans J, Sawant S, Sindone J, Lal S. Sex-specific differences in the efficacy of heart failure therapies: a meta-analysis of 84,818 patients. Heart Fail Rev 2023;28:949-59.
73. Mathews L, Ding N, Sang Y, et al. Racial differences in trends and prognosis of guideline-directed medical therapy for heart failure with reduced ejection fraction: the atherosclerosis risk in communities (ARIC) surveillance study. J Racial Ethn Health Disparities 2023;10:118-29.
74. Witting C, Zheng J, Tisdale RL, et al. Treatment differences in medical therapy for heart failure with reduced ejection fraction between sociodemographic groups. JACC Heart Fail 2023;11:161-72.
75. Chandra R, Meier J, Khoury MK, et al. Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG. Semin Thorac Cardiovasc Surg 2022;9:S1043-0679(22)00230.
77. Torabi AJ, Mshelbwala FS, Hugenberg D, Kovacs RJ, Kreutz RP. Social deprivation index and ischemic events after percutaneous coronary intervention in patients with diabetes mellitus. Catheter Cardiovasc Interv 2022;99:1015-21.
78. Hravnak M, Ibrahim S, Kaufer A, Sonel A, Conigliaro J. Racial disparities in outcomes following coronary artery bypass grafting. J Cardiovasc Nurs 2006;21:367-78.
79. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA 2012;307:813-22.
80. Anand SS, Islam S, Rosengren A, et al. Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. Eur Heart J 2008;29:932-40.
81. Worrall-Carter L, McEvedy S, Wilson A, Rahman MA. Gender differences in presentation, coronary intervention, and outcomes of 28,985 acute coronary syndrome patients in Victoria, Australia. Women's Health Issues 2016;26:14-20.
82. Cepas-Guillen PL, Echarte-Morales J, Flores-Umanzor E, et al. Sex-gender disparities in nonagenarians with acute coronary syndrome. Clin Cardiol 2021;44:371-8.
83. Koh Y, Stehli J, Martin C, et al. Does sex predict quality of life after acute coronary syndromes: an Australian, state-wide, multicentre prospective cohort study. BMJ Open 2019;9:e034034.
84. Yu J, Baber U, Mastoris I, et al. Sex-based differences in cessation of dual-antiplatelet therapy following percutaneous coronary intervention with stents. JACC Cardiovasc Interv 2016;9:1461-9.
85. Venetsanos D, Sederholm Lawesson S, Alfredsson J, et al. Association between gender and short-term outcome in patients with ST elevation myocardial infraction participating in the international, prospective, randomised Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery (ATLANTIC) trial: a prespecified analysis. BMJ Open 2017;7:e015241.
86. Ezekowitz JA, Savu A, Welsh RC, McAlister FA, Goodman SG, Kaul P. Is there a sex gap in surviving an acute coronary syndrome or subsequent development of heart failure? Circulation 2020;142:2231-9.
87. Lloyd-Jones DM, Larson MG, Leip EP, et al. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation 2002;106:3068-72.
88. Zou Y, Zhu W, Zeng J, Lin J, Dai S. Sex-differences in the management and clinical outcome among patients with acute coronary syndrome. BMC Cardiovasc Disord 2021;21:609.
89. Hao Y, Liu J, Liu J, et al. Sex differences in in-hospital management and outcomes of patients with acute coronary syndrome. Findings from the CCC project. Circulation 2019;139:1776-85.
90. Manfrini O, Yoon J, van der Schaar M, et al. Sex differences in modifiable risk factors and severity of coronary artery disease. J Am Heart Assoc 2020;9:e017235.
91. Gordon T, Kannel WB, Hjortland MC, McNamara PM. Menopause and coronary heart disease. The Framingham Study. Ann Intern Med 1978;89:157-61.
92. Jones DW, Chambless LE, Folsom AR, et al. Risk factors for coronary heart disease in African Americans: the atherosclerosis risk in communities study, 1987-1997. Arch Intern Med 2002;162:2565-71.
93. Anstey D, Li S, Thomas L, Wang TY, Wiviott SD. Race and sex differences in management and outcomes of patients after ST-elevation and Non-ST-elevation myocardial infarct: results from the NCDR. Clin Cardiol 2016;39:585-95.
94. Weight N, Moledina S, Sun L, et al. Ethnic disparities in ST-segment elevation myocardial infarction outcomes and processes of care in patients with and without standard modifiable cardiovascular risk factors: a nationwide cohort study. Angiology 2023. Online ahead of print.
95. Cromwell J, McCall NT, Burton J, Urato C. Race/ethnic disparities in utilization of lifesaving technologies by medicare ischemic heart disease beneficiaries. Med Care 2005;43:330-7.
96. Gauri AJ, Davis A, Hong T, Burke MC, Knight BP. Disparities in the use of primary prevention and defibrillator therapy among blacks and women. Am J Med 2006;119:167.e17-21.
97. Ingelaere S, Hoffmann R, Guler I, et al. Inequality between women and men in ICD implantation. Int J Cardiol Heart Vasc 2022;41:101075.
98. Ilonze O, Free K, Breathett K. Unequitable heart failure therapy for black, hispanic and American-Indian patients. Card Fail Rev 2022;8:e25.
99. Greene SJ, Butler J, Albert NM, et al. Medical therapy for heart failure with reduced ejection fraction: The CHAMP-HF registry. J Am Coll Cardiol 2018;72:351-66.
100. Ziaeian B, Kominski GF, Ong MK, Mays VM, Brook RH, Fonarow GC. National differences in trends for heart failure hospitalizations by sex and race/ethnicity. Circ Cardiovasc Qual Outcomes 2017;10:e003552.
101. Smilowitz NR, Maduro GA Jr, Lobach IV, Chen Y, Reynolds HR. Adverse trends in ischemic heart disease mortality among young New Yorkers, particularly young black women. PLoS One 2016;11:e0149015.
102. Angraal S, Khera R, Wang Y, et al. Sex and race differences in the utilization and outcomes of coronary artery bypass grafting among medicare beneficiaries, 1999-2014. J Am Heart Assoc 2018;7:e009014.
103. Bhatia N, Vakil D, Zinonos S, et al. US initiative to eliminate racial and ethnic disparities in health: the impact on the outcomes of ST-segment-elevation myocardial infarction in New Jersey. J Am Heart Assoc 2023;12:e026954.
104. Gaudino M, Di Franco A, Alexander JH, et al. Sex differences in outcomes after coronary artery bypass grafting: a pooled analysis of individual patient data. Eur Heart J 2021;43:18-28.
105. Attia T, Koch CG, Houghtaling PL, Blackstone EH, Sabik EM, Sabik JF 3rd. Does a similar procedure result in similar survival for women and men undergoing isolated coronary artery bypass grafting? J Thorac Cardiovasc Surg 2017;153:571-9.e9.
106. Thandra A, Jhand A, Guddeti R, et al. Sex differences in clinical outcomes following percutaneous coronary intervention of unprotected left main coronary artery: a systematic review and meta-analysis. Cardiovasc Revasc Med 2021;28:25-31.
107. Rangrass G, Ghaferi AA, Dimick JB. Explaining racial disparities in outcomes after cardiac surgery: the role of hospital quality. JAMA Surg 2014;149:223-7.
108. Enumah ZO, Canner JK, Alejo D, et al. Persistent racial and sex disparities in outcomes after coronary artery bypass surgery: a retrospective clinical registry review in the drug-eluting stent era. Ann Surg 2020;272:660-7.
109. Benedetto U, Kamel MK, Khan FM, et al. Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis. J Thorac Cardiovasc Surg 2019;157:2216-25.e4.
110. Becker ER, Rahimi A. Disparities in race/ethnicity and gender in in-hospital mortality rates for coronary artery bypass surgery patients. J Natl Med Assoc 2006;98:1729-39.
111. Spehar SM, Seth M, Henke P, et al. Race and outcomes after percutaneous coronary intervention: insights from the blue cross blue shield of Michigan cardiovascular consortium. Am Heart J 2023;255:106-16.
112. Nallamothu BK, Saint S, Saha S, Fendrick AM, Kelley K, Ramsey SD. Coronary artery bypass grafting in Native Americans: a higher risk of death compared to other ethnic groups? J Gen Intern Med 2001;16:554-9.
113. Wiemers PD, Fraser JF, Marney L, Yadav S, Tam R. A review of coronary artery bypass grafting in the indigenous australian population. Heart Lung Circ 2019;28:530-8.
114. Li S, Fonarow GC, Mukamal K, et al. Sex and racial disparities in cardiac rehabilitation referral at hospital discharge and gaps in long-term mortality. J Am Heart Assoc 2018;7:e008088.
115. Kaufman JS, Dolman L, Rushani D, Cooper RS. The contribution of genomic research to explaining racial disparities in cardiovascular disease: a systematic review. Am J Epidemiol 2015;181:464-72.
116. Chakrabarti S, Morton JS, Davidge ST. Mechanisms of estrogen effects on the endothelium: an overview. Can J Cardiol 2014;30:705-12.
117. Haug EB, Horn J, Markovitz AR, et al. Association of conventional cardiovascular risk factors with cardiovascular disease after hypertensive disorders of pregnancy: analysis of the nord-trøndelag health study. JAMA Cardiol 2019;4:628-35.
118. Retnakaran R, Shah BR. Glucose screening in pregnancy and future risk of cardiovascular disease in women: a retrospective, population-based cohort study. Lancet Diabetes Endocrinol 2019;7:378-84.
119. Makaryus AN, Jauhar R, Tortez LM, Pekmezaris R. Comparison of the diameters of the major epicardial coronary arteries by angiogram in Asian-Indians versus European Americans <40 years of age undergoing percutaneous coronary artery intervention. Am J Cardiol 2017;120:924-6.
120. Kang J, Kim HS. The evolving concept of dual antiplatelet therapy after percutaneous coronary intervention: focus on unique feature of east Asian and “Asian Paradox”. Korean Circ J 2018;48:537-51.
121. Liakos M, Parikh PB. Gender disparities in presentation, management, and outcomes of acute myocardial infarction. Curr Cardiol Rep 2018;20:64.
122. Mosca L, Mochari-Greenberger H, Dolor RJ, Newby LK, Robb KJ. Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health. Circ Cardiovasc Qual Outcomes 2010;3:120-7.
123. Kaul P, Armstrong PW, Sookram S, Leung BK, Brass N, Welsh RC. Temporal trends in patient and treatment delay among men and women presenting with ST-elevation myocardial infarction. Am Heart J 2011;161:91-7.
124. Crilly M, Bundred P, Hu X, Leckey L, Johnstone F. Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care. BMC Health Serv Res 2007;7:142.
125. Leifheit-Limson EC, D'Onofrio G, Daneshvar M, et al. Sex differences in cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction: the VIRGO study. J Am Coll Cardiol 2015;66:1949-57.
126. Foraker RE, Patel MD, Whitsel EA, Suchindran CM, Heiss G, Rose KM. Neighborhood socioeconomic disparities and 1-year case fatality after incident myocardial infarction: the atherosclerosis risk in communities (ARIC) community surveillance (1992-2002). Am Heart J 2013;165:102-7.
127. Dimick J, Ruhter J, Sarrazin MV, Birkmeyer JD. Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions. Health Aff 2013;32:1046-53.
128. Preventza O, Critsinelis A, Simpson K, et al. Sex, racial, and ethnic disparities in U.S. cardiovascular trials in more than 230,000 patients. Ann Thorac Surg 2021;112:726-35.
129. Scott PE, Unger EF, Jenkins MR, et al. Participation of women in clinical trials supporting FDA approval of cardiovascular drugs. J Am Coll Cardiol 2018;71:1960-9.
130. Kullo IJ, Bailey KR, Kardia SL, Mosley TH Jr, Boerwinkle E, Turner ST. Ethnic differences in peripheral arterial disease in the NHLBI genetic epidemiology network of arteriopathy (GENOA) study. Vasc Med 2003;8:237-42.
131. NOT-OD-18-014. Amendment: NIH policy and guidelines on the inclusion of women and minorities as subjects in clinical research. 2017. Available from: https://grants.nih.gov/grants/guide/notice-files/NOT-OD-18-014.html [Last accessed on 24 Nov 2023].
132. Hannan EL, Wu Y, Cozzens K, et al. The association of socioeconomic factors with outcomes for coronary artery bypass surgery. Ann Thorac Surg 2022;114:1318-25.
133. Hannan EL, Wu Y, Cozzens K, et al. The association of socioeconomic factors with percutaneous coronary intervention outcomes. Can J Cardiol 2022;38:13-22.
134. Patrick WL, Bojko M, Han JJ, et al. Neighborhood socioeconomic status is associated with differences in operative management and long-term survival after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2022;164:92-102.e8.
135. Vervoort D, Swain JD, Fiedler AG. A seat at the table: the cardiothoracic surgeon as surgeon-advocate. Ann Thorac Surg 2021;111:741-4.
136. Haynes N, Kaur A, Swain J, Joseph JJ, Brewer LC. Community-based participatory research to improve cardiovascular health among us racial and ethnic minority groups. Curr Epidemiol Rep 2022;9:212-21.
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Ghunaim, A. H.; Vervoort D.; Elfaki L. A.; Deng M. X.; Marquis-Gravel G.; Fremes S. E. Disparities in therapies for coronary artery disease with reduced left ventricular ejection fraction. Vessel. Plus. 2023, 7, 29. http://dx.doi.org/10.20517/2574-1209.2023.112
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