Sex differences in long-term outcomes of patients across the spectrum of coronary artery disease

Abstract

Background Patients with nonobstructive coronary artery disease (CAD) have worse outcomes compared with those without CAD; however, few studies have compared the intermediate- and long-term impact of CAD severity as a function of patient sex. Methods We evaluated 5-year and long-term all-cause mortality of women and men undergoing elective coronary angiography at a single center by degree of CAD: no CAD (1%−24% stenosis), nonobstructive CAD (25%−69% epicardial stenosis or 25%−49% left main stenosis), or obstructive CAD (epicardial stenosis ≥70% or left main stenosis ≥50%), both overall and after adjusting for baseline clinical risk factors using Cox proportional-hazards models. Results Between January 1986 and July 2010, 8,766 women and 11,638 men underwent angiography and were followed for a median of 9.2 years. The majority (67%) of women had no CAD or nonobstructive CAD, whereas the majority of men had obstructive CAD (56%, P < .001). In both sexes, increasing CAD was associated with increased 5-year risk of mortality. Risk-adjusted hazard ratios (vs no CAD) for women were 1.36 (95% CI, 1.16–1.60) and 1.86 (1.61–2.16) for nonobstructive and obstructive CAD, respectively; corresponding hazard ratios for men were 1.24 (1.06–1.45) and 1.38 (1.20–1.59). After risk adjustment, 5-year mortality risk was higher in men than in women at all levels of CAD severity. The relationships between severity of CAD and mortality risk during long-term follow-up in women and men were similar to the 5-year relationships above. Conclusions Although women undergoing elective catheterization have less severe CAD than men, nonobstructive CAD is prevalent in both sexes and carries a worse prognosis than no CAD. These data suggest a need for further investigation to establish optimal therapies for this at-risk group of patients with nonobstructive CAD. (Am Heart J 2018;206:51–60.)

Long‐term outcomes in patients with normal coronary arteries, nonobstructive, or obstructive coronary artery disease on invasive coronary angiography

“…No gender differences in prescribing aspirin or statins were observed. This is in contrast to the findings of another recently reported study in patients with nonobstructive CAD identified after ICA, in which women were less likely than men to report statin use at follow‐up 7 …”

“…A third meta‐analysis of studies employing CCTA demonstrated that the annual mortality was 0.74% in patients with nonobstructive CAD compared to 0.15% for patients with normal coronary arteries 6 . In a large observational single center study of 11 000 patients undergoing ICA, those with nonobstructive CAD had a worse prognosis than patients with no CAD 7 . The risk of cardiovascular events has been described to be related to the extent of nonobstructive CAD/plaque burden and the number of coronary vessels involved 7,8,25,26 .…”

“…In a large observational single center study of 11 000 patients undergoing ICA, those with nonobstructive CAD had a worse prognosis than patients with no CAD 7 . The risk of cardiovascular events has been described to be related to the extent of nonobstructive CAD/plaque burden and the number of coronary vessels involved 7,8,25,26 . The more extensive the plaque burden in patients with nonobstructive CAD, the higher the subsequent cardiac event rate 27–29 .…”

“…In the PROMISE trial, 20% of patients enrolled in the CCTA arm had nonobstructive CAD defined as 30%–50% stenosis 3 . The death or nonfatal myocardial infarction (NFMI) rate has universally been reported to be higher in patients with nonobstructive CAD compared to patients found to have NNCA 4–10 . The death or MI rate for patients with non‐ST‐elevation (NSTEMI) and nonobstructive CAD is reported to be 3.5 times higher than in NSTEMI patients with NNCA 5 .…”

“… 3 The death or nonfatal myocardial infarction (NFMI) rate has universally been reported to be higher in patients with nonobstructive CAD compared to patients found to have NNCA. 4 , 5 , 6 , 7 , 8 , 9 , 10 The death or MI rate for patients with non‐ST‐elevation (NSTEMI) and nonobstructive CAD is reported to be 3.5 times higher than in NSTEMI patients with NNCA. 5 Some prior reports have suggested that cardiac event rates are higher in women with nonobstructive CAD than in men.…”