Xie Joe X, Eshtehardi Parham, Varghese Tina, Goyal Abhinav, Mehta Puja K, Kang William, Leipsic Jonathon, Ó Hartaigh Bríain, Bairey Merz C Noel, Berman Daniel S, Gransar Heidi, Budoff Matthew J, Achenbach Stephan, Callister Tracy Q, Marques Hugo, Rubinshtein Ronen, Al-Mallah Mouaz H, Andreini Daniele, Pontone Gianluca, Cademartiri Filippo, Maffei Erica, Chinnaiyan Kavitha, Raff Gilbert, Hadamitzky Martin, Hausleiter Joerg, Feuchtner Gudrun, Kaufmann Philipp A, Villines Todd C, Chow Benjamin J W, Min James K, Shaw Leslee J
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.).
Circ Cardiovasc Imaging. 2017 Aug;10(8). doi: 10.1161/CIRCIMAGING.117.006246.
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.
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%; <0.0001); men (24.6% versus 18.2%; <0.0001). A significant interaction existed between sex and LM status for the composite outcome (=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; =0.005) but not in men (adjusted hazard ratio, 0.98, =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; =0.017); sex-specific interactions were not observed across other patterns (eg, location or extent) of nonobstructive plaque.
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.
患有阻塞性（狭窄≥50%）左主干（LM）冠状动脉疾病（CAD）的患者发生不良事件的风险很高；先前的研究也表明，患有严重多支血管/LM CAD的女性患者的预后比男性更差。然而，非阻塞性（狭窄1%-49%）LM CAD的预后意义，包括性别差异，此前尚未得到研究。
在长期的CONFIRM（冠状动脉CT血管造影临床结果评估：一项国际多中心研究）注册研究中，患者因疑似CAD接受了选择性冠状动脉计算机断层血管造影，并随访了5年。在排除患有阻塞性LM CAD的患者后，5166例患者被归类为LM正常或非阻塞性LM（占队列的18%）。在女性和男性中，非阻塞性LM患者的5年累计死亡、心肌梗死或血运重建发生率均高于LM正常的患者：女性（34.3%对15.4%；<0.0001）；男性（24.6%对18.2%；<0.0001）。复合结局的性别和LM状态之间存在显著交互作用（P=0.001）。在多变量Cox回归分析中，非阻塞性LM斑块的存在增加了女性复合结局的风险（调整后风险比，1.48；P=0.005），但在男性中未增加（调整后风险比，0.98，P=0.806）。在亚组分析中，患有非阻塞性LM CAD的女性发生事件的风险比患有非阻塞性LM CAD的男性高近80%（调整后风险比，1.78；P=0.017）；在非阻塞性斑块的其他模式（如位置或范围）中未观察到性别特异性交互作用。
冠状动脉计算机断层血管造影经常检测到非阻塞性LM CAD，且其与女性不良事件密切相关。认识到非阻塞性LM斑块的性别特异性预后意义可能会加强风险分层工作。
