Sex Differences in Coronary Revascularization Strategies and Outcomes in Patients Undergoing Dialysis

Key Points Among patients undergoing dialysis with acute coronary syndrome, women received less treatment with coronary artery bypass graft or percutaneous coronary intervention than men. Women, as compared with men, had a lower risk of all-cause death with percutaneous coronary intervention and no difference in all-cause death with coronary artery bypass graft. Background Coronary artery disease is the leading cause of mortality among both men and women with ESKD in the United States. A critical knowledge gap exists on sex differences in revascularization strategies and outcomes in dialysis patients. Methods We evaluated 59,951 patients who initiated dialysis between January 1, 2005, and December 31, 2018, and had a primary diagnosis of acute coronary syndrome (ACS) using the United States Renal Data System database. We examined the association of sex with initial cardiac revascularization (defined as coronary artery bypass graft [CABG], percutaneous coronary intervention [PCI], or both on the same day) within 30 days of the first new ACS event after dialysis initiation and examined the association of sex and initial cardiac revascularization with the outcome of all-cause death. Results Women comprised 44.3% of the cohort. Among patients with first new ACS event after dialysis initiation, 34.6% received PCI, 14.7% received CABG, and 6.1% received both CABG and PCI. After the first new ACS event after dialysis initiation, women had a 42% lower likelihood of receiving CABG only (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.55 to 0.61), 14% lower likelihood of receiving PCI only (OR, 0.86; 95% CI, 0.83 to 0.90), and 41% lower likelihood of receiving CABG and PCI (OR, 0.59; 95% CI, 0.55 to 0.64) compared with men. Women had a slightly lower risk of all-cause death during the follow-up without treatment (Hazard ratios, 0.91; 95% CI, 0.88 to 0.94) or after receiving PCI (Hazard ratios, 0.96; 95% CI, 0.93 to 0.99), but no difference in all-cause death after receiving CABG, or after receiving both CABG and PCI compared with men. Conclusion Among patients undergoing dialysis with ACS, women received less treatment with CABG or PCI than men. Women had a lower risk of all-cause death with PCI and no difference in all-cause death with CABG compared with men.