Healio Interview

Disclosures: Cho and the other authors report no relevant financial disclosures.
November 03, 2021
5 min read

Q&A: Cardiac surgery frequently delayed for women, leading to poor outcomes


Healio Interview

Disclosures: Cho and the other authors report no relevant financial disclosures.
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In the contemporary CV clinical setting, women continue to present later and receive less aggressive care than men and experience a lower quality of life after cardiac surgery, according to an in-depth review published in Circulation.

Researchers also observed persistent sex bias in both basic and clinical science.

Graphical depiction of source quote presented in the article
Leslie Cho, MD, director of the Cleveland Clinic’s Women’s Cardiovascular Center.

According to the report, one in three women die of CVD and approximately 45% of women older than 20 years have some form of CVD. Despite advances in cardiac surgery technique and perioperative management, women experience poorer outcomes and quality of life after surgery.

Healio spoke with Leslie Cho, MD, director of the Cleveland Clinic’s Women’s Cardiovascular Center, about these inequities and what can be done to correct these disparities in timely diagnosis, risk stratification and the knowledge gap created by sex-biased research.

Healio: Can you provide some background for this report?

Cho: This is a comprehensive overview of cardiac surgery in women. There is a lot of prior research, but we wanted to see whether anything has changed in the last 2 decades. While we’ve made some progress, we are, unfortunately, still finding out that women, whether it is aortic, bypass or valve surgery, are getting to surgery later than men. It’s also important to understand that the pathophysiology of some of these conditions are different between men and women. This report is an overview of that. As we, as a society, become more in tune to precision medicine, meaning trying to tailor our therapies for patients, it’s really important to be mindful about these ongoing sex disparities.

Healio: Its noted in the report that women tend to present later in disease progression compared with men. Why is that?

Cho: There are good data about women’s presentation. Many times, there are gender differences in referral to specialist care. That’s a big point because most of these treatments are done by specialists at tertiary centers, and so late referrals means deferred care. Whether it’s a patient preference or whether it’s a physician bias, I don’t know, but women are referred to specialty clinics later on.

Also, there are some ongoing assessments looking into the criteria for when women go into to surgery because most of these criteria were developed in men. The timing of surgery also has to be tailored for women.

Healio: The report also mentions that women receive less aggressive therapies than men. Could you comment why?

Cho: One of the main reasons is that when women present later, they’re older and they have more comorbidities, and so they may be at higher surgical risk because they are delayed in their presentation or referral so they may not get more aggressive care.

Healio: What are some of the barriers faced by women regarding outcomes and quality of life after cardiac surgery?

Cho: Because women are delayed to surgical interventions, their outcomes are also less than optimal. For example, women with aortic stenosis frequently come in with left ventricular hypertrophy so even after aortic valve surgery, women continue to have diastolic dysfunction and have HF. This does not mean they should not undergo AV surgery, this just means they should have received earlier referral for intervention. If you look at women with bypass surgeries, they end up having more angina after surgery, and some of that has to do with the fact that they have more disease when they present: They have smaller arteries; they have diffuse disease and they have more comorbidities.

Also, there are very interesting data about thoracic aortic disease. Thoracic aneurysms grow faster in women. There is greater risk for rupture and dissection, and they are more likely to die. It’s important to size the aorta based on body size. That’s why it’s important to refer to specialty clinics or specialty centers, so these women can be treated appropriately and aggressively.

Healio: Are there any subgroups of women who face even greater disparities regarding cardiac surgery than others?

Cho: Women from historically underrepresented groups and women who live in rural areas face greater disparities. As for a particular state, patients with thoracic aortic disease. We really need to put more emphasis on tailoring their care.

Also important is that, unfortunately, women still make up a low proportion of patients in clinical trials. In some trials in cardiac surgery, that rate is even lower in the last 2 decades. We really need to remind our physicians as well as our patient population about the importance of aggressive care, close follow-up and being proactive with participation in clinical trials.

Healio: In what areas did you observe significant improvement for the women undergoing cardiac surgery?

Cho: TAVR is a real success story. The TAVR trials have done an outstanding job of enrolling both men and women. The researchers have done a tremendous job in terms of taking the highest-risk patients, who tend to be older women, and showing good outcomes.

We still have some room to improve in terms of coronary artery disease, but we continue to make good progress. The fact that we are raising awareness with the American College of Cardiology and American Heart Association is good. Women are getting more proactive. They’re getting to see their doctors about CAD sooner and are having those important conversations even earlier.

Healio: What other trends did you observe in clinical research?

Cho: There is something called participation prevalence ratio, or PPR. It is accepted by the FDA and is one of the benchmarks. The bar is 0.8 to 1.2, which suggests good representation that mirrors the community prevalence. Unfortunately, bypass surgery representation has gone down for women, and women still are not doing very well. Trial participation in the last 10 years hasn’t been great. It’s the same story for transplant and ventricular assist device trials, and the aortic trials have been poor with regard to participation of women. The PPR for surgical valve disease and CAD medical treatment trials are not great either.

The only areas we’ve done well for women are the TAVR trials and the trials of pulmonary hypertension. But, in general, we need to do better. It is discouraging to see that the number of women participating in bypass surgery, transplant and aortic aneurysm surgery has been poor. In some cases, it’s actually dropped in the last 10 years.

Healio: Why has participation dropped?

Cho: I’m not sure what the reason is, but what we need to do as a community is to demand that there be more equitable representation. It’s a call to action for women, too. There are historical data that say women don’t want to participate when asked. Part of that has to do with the fact that women tend to be caregivers. They tend to take care of their family, their elderly parents, their children or their husband. And so, because it takes time to come into the hospital, get seen and participate in clinical trials, it discourages women. But with remote care, we can overcome that.

The other thing that discourages women is that a lot of these trials have age exclusion criteria, and because women present later, they’re excluded. Every factor of our system has to make this a priority because when we approve medications or procedures, we do it for everybody, and yet if we only study it in a select group, predominantly men, it is not good.

Healio: What are the next steps to reducing these disparities in care, outcomes and clinical research representation?

Cho: There are several steps. We need to be cognizant and raising awareness is the first step. If no one thinks there is a problem, nothing is going to be done about it. Reports like this raise awareness, and raising awareness is where everything starts.

We need to continue to discuss disparities in care and how best to risk predict. Including sex as one of the prediction criteria is critical.

Regulators, insurance companies, patients and physicians should all engage in this conversation about how we provide optimal care for women. It’s a call to action to make cardiac surgery beneficial for everyone.

For more information:

Leslie Cho, MD, can be reached at