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Page 2 of 17 Ghunaim et al. Vessel Plus 2023;7:29 https://dx.doi.org/10.20517/2574-1209.2023.112

INTRODUCTION
Coronary artery disease (CAD) is the world’s leading cause of death due to myocardial infarction, heart
[3]
[1,2]
failure, and/or sudden death . Approximately 125 million people live with CAD worldwide . Risk factors
for atherosclerotic CAD notably include smoking, diabetes mellitus, dyslipidemia, hypertension, obesity,
[1]
and stress . 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
[1]
(STEMI) . 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 . In adults between the ages
[4]
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 and a financial toll of more than 40 billion U.S. dollars .
[4]
[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 . ICM accounts for almost half of all heart failure cases . It is often due to a mix of irreversible loss
[7,8]
[3]
[9]
of viable myocardium and regions of stunned but viable myocardium . 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
[10]
women 24% and 46% . 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
[10]
with preserved ejection fraction (HFpEF) . 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 . In this
[13]
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].

TREATMENT OF CAD WITH REDUCED LVEF
[14]
The Surgical Treatment for Ischemic Heart Failure (STICH, NCT00023595) trial and its extended follow-
up study (STICHES) provided the most comprehensive insights into revascularization of CAD with
[15]
LVSD. Comparing medical therapy plus CABG (n = 610) to medical therapy alone (n = 602), the risk of all-