Joe X Xie1, Parham Eshtehardi2, Tina Varghese2, Abhinav Goyal2, Puja K Mehta2, William Kang2, Jonathon Leipsic2, Bríain Ó Hartaigh2, C Noel Bairey Merz2, Daniel S Berman2, Heidi Gransar2, Matthew J Budoff2, Stephan Achenbach2, Tracy Q Callister2, Hugo Marques2, Ronen Rubinshtein2, Mouaz H Al-Mallah2, Daniele Andreini2, Gianluca Pontone2, Filippo Cademartiri2, Erica Maffei2, Kavitha Chinnaiyan2, Gilbert Raff2, Martin Hadamitzky2, Joerg Hausleiter2, Gudrun Feuchtner2, Philipp A Kaufmann2, Todd C Villines2, Benjamin J W Chow2, James K Min2, Leslee J Shaw2. 1. From the Department of Cardiology, Emory University School of Medicine, Atlanta, GA (J.X.X., P.E., T.V., A.G., P.K.M., W.K., L.J.S.); Department of Cardiology, University of British Columbia, Vancouver, Canada (J.L.); Department of Cardiology, Weill Cornell Medical College and the New York Presbyterian Hospital, NY (B.ó.H., J.K.M.); Department of Cardiology, Barbara Stresiand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA (C.N.B.M., D.S.B., H.G.); Department of Cardiology, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); Department of Cardiology, University of Erlangen, Germany (S.A.); Department of Cardiolog, Tennessee Heart and Vascular Institute, Hendersonville, TN (T.Q.C.); Department of Cardiology, Hospital da Luz, Lisbon, Portugal (H.M.); Department of Cardiology, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (R.R.); Department of Cardiology, Henry Ford Hospital, Detroit, MI (M.H.A.-M.); Department of Cardiology, University of Milan, Centro Cardiologico Monzino, IRCCS, Italy (D.A., G.P.); Department of Radiology/Centre de Recherche, Montreal Heart Institute/Universitè de Montreal, Quebec, Canada (F.C., E.M.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (K.C., G.R.); Department of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany (M.H.); Department of Cardiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany (J.H.); Department of Cardiology, Medical University of Innsbruck, Austria (G.F.); Department of Cardiology, University Hospital, Zurich, Switzerland (P.A.K.); Department of Cardiology, Walter Reed Medical Center, Washington, DC (T.C.V); Department of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C.). joe.xie@emory.edu. 2. From the Department of Cardiology, Emory University School of Medicine, Atlanta, GA (J.X.X., P.E., T.V., A.G., P.K.M., W.K., L.J.S.); Department of Cardiology, University of British Columbia, Vancouver, Canada (J.L.); Department of Cardiology, Weill Cornell Medical College and the New York Presbyterian Hospital, NY (B.ó.H., J.K.M.); Department of Cardiology, Barbara Stresiand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA (C.N.B.M., D.S.B., H.G.); Department of Cardiology, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); Department of Cardiology, University of Erlangen, Germany (S.A.); Department of Cardiolog, Tennessee Heart and Vascular Institute, Hendersonville, TN (T.Q.C.); Department of Cardiology, Hospital da Luz, Lisbon, Portugal (H.M.); Department of Cardiology, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (R.R.); Department of Cardiology, Henry Ford Hospital, Detroit, MI (M.H.A.-M.); Department of Cardiology, University of Milan, Centro Cardiologico Monzino, IRCCS, Italy (D.A., G.P.); Department of Radiology/Centre de Recherche, Montreal Heart Institute/Universitè de Montreal, Quebec, Canada (F.C., E.M.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (K.C., G.R.); Department of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany (M.H.); Department of Cardiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany (J.H.); Department of Cardiology, Medical University of Innsbruck, Austria (G.F.); Department of Cardiology, University Hospital, Zurich, Switzerland (P.A.K.); Department of Cardiology, Walter Reed Medical Center, Washington, DC (T.C.V); Department of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C.).
Abstract
BACKGROUND: Patients with obstructive (≥50% stenosis) left main (LM) coronary artery disease (CAD) are at high risk for adverse events; prior studies have also documented worse outcomes among women than men with severe multivessel/LM CAD. However, the prognostic significance of nonobstructive (1%-49% stenosis) LM CAD, including sex-specific differences, has not been previously examined. METHODS AND RESULTS: In the long-term CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter) registry, patients underwent elective coronary computed tomographic angiography for suspected CAD and were followed for 5 years. After excluding those with obstructive LM CAD, 5166 patients were categorized as having normal LM or nonobstructive LM (18% of cohort). Cumulative 5-year incidence of death, myocardial infarction, or revascularization was higher among patients with nonobstructive LM than normal LM in both women and men: women (34.3% versus 15.4%; P<0.0001); men (24.6% versus 18.2%; P<0.0001). A significant interaction existed between sex and LM status for the composite outcome (P=0.001). In multivariable Cox regression, the presence of nonobstructive LM plaque increased the risk for the composite outcome in women (adjusted hazard ratio, 1.48; P=0.005) but not in men (adjusted hazard ratio, 0.98, P=0.806). In subgroup analysis, women with nonobstructive LM CAD had a nearly 80% higher risk for events than men with nonobstructive LM CAD (adjusted hazard ratio, 1.78; P=0.017); sex-specific interactions were not observed across other patterns (eg, location or extent) of nonobstructive plaque. CONCLUSION: Nonobstructive LM CAD was frequently detected on coronary computed tomographic angiography and strongly associated with adverse events among women. Recognizing the sex-specific prognostic significance of nonobstructive LM plaque may augment risk stratification efforts.
BACKGROUND:Patients with obstructive (≥50% stenosis) left main (LM) coronary artery disease (CAD) are at high risk for adverse events; prior studies have also documented worse outcomes among women than men with severe multivessel/LM CAD. However, the prognostic significance of nonobstructive (1%-49% stenosis) LM CAD, including sex-specific differences, has not been previously examined. METHODS AND RESULTS: In the long-term CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter) registry, patients underwent elective coronary computed tomographic angiography for suspected CAD and were followed for 5 years. After excluding those with obstructive LM CAD, 5166 patients were categorized as having normal LM or nonobstructive LM (18% of cohort). Cumulative 5-year incidence of death, myocardial infarction, or revascularization was higher among patients with nonobstructive LM than normal LM in both women and men: women (34.3% versus 15.4%; P<0.0001); men (24.6% versus 18.2%; P<0.0001). A significant interaction existed between sex and LM status for the composite outcome (P=0.001). In multivariable Cox regression, the presence of nonobstructive LM plaque increased the risk for the composite outcome in women (adjusted hazard ratio, 1.48; P=0.005) but not in men (adjusted hazard ratio, 0.98, P=0.806). In subgroup analysis, women with nonobstructive LM CAD had a nearly 80% higher risk for events than men with nonobstructive LM CAD (adjusted hazard ratio, 1.78; P=0.017); sex-specific interactions were not observed across other patterns (eg, location or extent) of nonobstructive plaque. CONCLUSION: Nonobstructive LM CAD was frequently detected on coronary computed tomographic angiography and strongly associated with adverse events among women. Recognizing the sex-specific prognostic significance of nonobstructive LM plaque may augment risk stratification efforts.
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