Sex-Specific Associations Between Coronary Artery Plaque Extent and Risk of Major Adverse Cardiovascular Events: The CONFIRM Long-Term Registry

OBJECTIVES: The purpose of this study was to examine sex-specific associations, if any, between per-vessel coronary artery disease (CAD) extent and the risk of major adverse cardiovascular events (MACE) over a 5-year study duration. The presence and extent of CAD diagnosed by coronary computed tomography angiography (CTA) is associated with increased short-term mortality and MACE. Nevertheless, some uncertainty remains regarding the influence of sex on these findings.

METHODS: 5,632 patients (mean age 60.2 ± 11.8 years, 36.5% women) from the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry were followed for 5 years. Obstructive CAD was defined as ≥50% luminal stenosis in a coronary vessel. Using Cox proportional hazards models, we calculated the hazard ratio (HR) for incident MACE among women and men, defined as death or myocardial infarction.

RESULTS: Obstructive CAD was more prevalent in men (42% vs. 26%; p < 0.001), whereas women were more likely to have normal coronary arteries (43% vs. 27%; p < 0.001). There were a total of 798 incident MACE events. After adjustment, there was a strong association between increased MACE risk and nonobstructive CAD (HR: 2.16 for women, 2.56 for men; p < 0.001 for both), obstructive 1-vessel CAD (HR: 3.69 and 2.66; p < 0.001), 2-vessel CAD (HR: 3.92 and 3.55; p < 0.001), and 3-vessel/left main CAD (HR: 5.94 and 4.44; p < 0.001). Further exploratory analyses of atherosclerotic burden did not identify sex-specific patterns predictive of MACE.

CONCLUSIONS: In a large prospective coronary CTA cohort followed long-term, we did not observe an interaction of sex for the association between MACE risk and increased per-vessel extent of obstructive CAD. These findings highlight the persistent prognostic significance of anatomic CAD subsets as detected by coronary CTA for the risk of MACE in both women and men.
COMPETENCY IN MEDICAL KNOWLEDGE: Greater per-vessel extent of obstructive CAD as detected by coronary CTA is associated with greater MACE risk over a 5-year duration. Because there was no observed interaction for this association, this holds true of CAD detected in both women and men.

TRANSLATIONAL OUTLOOK: Although rigorous and clinically relevant, the measures of CAD extent used in the present study are relatively crude. Further studies are needed to distinguish whether there are sex-specific plaque characteristics detected by coronary CTA and whether these are associated with a higher risk of clinical events. 


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One Comment

  1. Editorial Comment:

    Correlation Among Coronary CT Findings, Sex, and Events
    Should We Wait to CONFIRM?

    Kim Allan Williams, Sr., MDa; Sarah Alexander, MDb

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