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Ghunaim et al. Vessel Plus 2023;7:29 https://dx.doi.org/10.20517/2574-1209.2023.112 Page 9 of 17

angiotensin-converting enzyme inhibitors or angiotensin II receptor blocker (OR 1.57, 95%CI: 1.13-2.18;
P = 0.008), compared to White patients due to higher rates of hypertension among Black patients [98,99] .
Further, compared to White patients, Black patients with heart failure have a higher hospitalization rate
[100]
(percentage relative to White patients: 229% for men and 240% for women) . While mortality rates in
ICM declined in the past few decades, Black women aged 35-54 years experienced the least improvement in
mortality rates (1.5%) compared to women of other race/ethnicity groups (3.5% in Asian women, 3.2% in
White women, and 2.3% in Hispanic women) .
[101]

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
[52]
comorbidity profiles . Women also experience delays in revascularization from symptom onset compared
to men (14.4 h vs. 7.2 h) . Following CABG, women have higher major adverse cardiac and
[88]
[104]
cerebrovascular events, with a higher incidence of MI and repeat revascularization compared to men .
These differences persist despite off-pump surgery and MAG . Overall, women have higher mortality
[104]
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) . With regards to PCI, women have higher major adverse cardiac events
[105]
(OR 1.17 [1.01-1.36]) and myocardial infarction (OR 1.42 [1.07-1.87]) rates compared to men but similar
[106]
all-cause mortality, cardiac mortality, and target lesion revascularization . Recognizing that the majority
of the sex-based analyses for revascularization outcomes are derived from patients with preserved LV
function, the impact of revascularization strategy on women with reduced LVEF remains to be investigated.

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) . Black patients also experience longer
[110]
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
(OR 7.1 [2.5-20.3]), and Asian (OR 2.8 [1.1-7.0]) patients [112,113] . Cardiac rehabilitation referral is associated
with a 40% lower 3-year all-cause mortality, yet women are 12% less likely to receive a referral than men at
time of discharge, and Black, Hispanic, and Asian patients are 20, 36, and 50% less likely to receive referrals
than White patients . Compared to men, women are also less likely to receive physical activity
[114]
recommendations (OR 0.91 [0.86-0.96]) after admission for CAD or peripheral vascular disease.

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 . Studies suggest multiple interrelated causes.
[115]