Understanding Sex Differences in Coronary Artery Disease Risk
Is Coronary Anatomy Sufficient?
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Nonobstructive coronary artery disease (CAD) is not a benign phenotype, and its associated risks, including that of cardiac death and myocardial infarction, are increasingly recognized.1,2 Previously, diagnosis and management have focused on obstructive CAD, often defined as luminal narrowing of ≥70% in the epicardial coronary vessels or ≥50% in the left main (LM) artery on invasive angiography. Yet recent observational studies have revealed stepwise incremental risk for future adverse events in patients along a continuum of both severity (ie, mild, moderate, or severe stenosis) and extent (ie, number of involved segments or vessels) of CAD.1–4 Accelerated by the growth of noninvasive coronary computed tomographic angiography (CCTA), which both increases test sensitivity for diagnosis of CAD and enables characterization of plaque morphology, mounting evidence now supports that (1) the presence of any atherosclerotic plaque, obstructive or not, portends increased risk of events and (2) the higher the overall plaque burden that is present, the higher the risk. This has also led to insights into prevalent patterns of disease, which seem to differ between women and men, with more symptomatic women than men manifesting nonobstructive rather than obstructive CAD,1,5 with important implications for diagnosis and management.
See Article by Xie et al
In this issue of Circulation: Cardiovascular Imaging, Xie et al6 report on a post hoc analysis of the prognostic significance of nonobstructive LM CAD in a subset of women and men enrolled in the international multicenter CCTA CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry. In an earlier report from the CONFIRM registry, 23 854 consecutive patients without known CAD, who underwent CCTA between 2005 and 2009 (33% of whom were asymptomatic at time of testing), were followed up for a mean of 2.3 years for …