Author + information
- Mathijs O. Versteylen, MD, PhD∗ (, )
- Ivo A. Joosen, MD, PhD,
- Bas L. Kietselaer, MD, PhD,
- Joachim E. Wildberger, MD, PhD,
- Harry J. Crijns, MD, PhD and
- Leonard Hofstra, MD, PhD
- ↵∗Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P Debyelaan 25, Maastricht, the Netherlands.
The prognostic value of coronary computed tomographic angiography (CTA) is emerging, and especially detected obstructive coronary artery disease (CAD) is a strong independent predictor for events (1). Meanwhile, the pathophysiology of acute coronary syndromes in men and women differs. In contrast to events in men, coronary events in women occur more often in the absence of obstructive CAD (2) and are frequently based on plaque erosion (3,4). The goal of this study was to investigate the ability of coronary CTA to predict coronary events, in both men and women with stable chest pain.
We prospectively investigated 1,210 stable chest pain patients who underwent coronary CTA between January 1, 2007 and June 1, 2010. The institution’s ethics committee approved the study. Using the American Heart Association’s 16-segment model, CAD was reported for every segment as no CAD (no lesion), nonobstructive CAD (lesion with diameter stenosis <50%), or obstructive CAD (lesion with diameter stenosis ≥50%). Patients were subsequently categorized as having no CAD, any CAD (≥1 nonobstructive and/or obstructive lesions), or obstructive CAD (≥1 obstructive lesions).
The study group consisted of 640 men (53%) and 570 women (47%). Women, as compared with men, were significantly older (58 ± 11 years vs. 56 ± 11 years, p < 0.001), more often had a positive family history (43% vs. 33%, p < 0.001) and typical chest pain (15% vs. 9%, p = 0.002). On the other hand, men, as compared with women, more often had any CAD (70% vs. 56%, p < 0.001) as well as obstructive CAD (34% vs. 21%, p < 0.001).
Patients were followed up for a mean 1,166 ± 269 days. A total of 3 cardiac deaths, 12 myocardial infarctions, 7 unstable angina, and 38 late revascularizations (>60 days after CTA) were reported (n = 60 coronary events; 38 occurred in men and 22 in women, p = 0.11). The presence of obstructive CAD predicted significantly the occurrence of the combined endpoint, both in men and women. The annualized event rate for men with and without obstructive CAD was 5.12% and 0.15% (p < 0.001). For women with and without obstructive CAD, the annualized event rate was 4.83% and 0.28% (p < 0.001). Moreover, for men and women without any CAD, the annualized event rate was 0% and 0.39% (p = 0.26). There were no significant interactions between sex and obstructive or any CAD (p = 0.54 and p = 0.15). In Figure 1, Kaplan-Meier curves were calculated to assess sex differences in patients: 1) with and without obstructive CAD; and 2) with and without any CAD. The presence of obstructive CAD as well as any CAD clearly resulted in a worse outcome for both men and women. In a Cox regression model, the hazard ratio for obstructive CAD was 37.2 (95% confidence interval [CI]: 8.9 to 154.3; p < 0.001) in men and 18.4 (95% CI: 6.2 to 54.4; p < 0.001) in women. In an exploratory adjusted model, controlling for traditional risk factors, the hazard ratio for obstructive CAD remained predictive (p < 0.001) in women. Also in men, the presence of obstructive CAD was an independent predictor; hazard ratio = 36.9 (95% CI: 8.9 to 153.3; p < 0.001). Sex was not predictive of outcome (p = 0.71).
A limitation of this study is that coronary CTA was performed within clinical workup, which could implicate referral bias. Possibly, clinical information known to the reader might have influenced coronary CTA assessment as well. The nonsignificant difference in event rate between men and women with normal coronary CTA might be due to differences in risk factors or referral patterns, which this study did not have the power to detect.
In conclusion, obstructive CAD significantly predicted events in both men and women. Despite the small numbers and hypothesis-generating nature of our study, these findings further validate the role of coronary CTA to effectively risk stratify women and men.
Please note: Dr. Wildberger has received institutional grants from Bayer Healthcare, Siemens Healthcare, GE Healthcare, Philips Healthcare, Agfa Healthcare, and Bracco. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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