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

Background: Coronary artery disease is the leading cause of mortality among both men and women with end-stage kidney disease (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 1/1/2005 and 12/31/2018 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: Females 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, females had a 42% lower likelihood of receiving CABG only (OR, 0.58; 95% CI, 0.55-0.61), 14% lower likelihood of receiving PCI only (OR, 0.86; 95% CI, 0.83-0.90), and 41% lower likelihood of receiving CABG and PCI (OR, 0.59; 95% CI, 0.55-0.64) compared to males. Females had a slightly lower risk of all-cause death during the follow-up without treatment (HR, 0.91; 95% CI, 0.88-0.94) or after receiving PCI (HR, 0.96; 95% CI, 0.93-0.99), but no difference in all-cause death after receiving CABG, or after receiving both CABG and PCI compared to males. Conclusion: Among patients undergoing dialysis with ACS, females received less treatment with CABG or PCI than males. Females had a lower risk of all-cause death with PCI and no difference in all-cause death with CABG compared to males.