Influence of Sex on Relationship Between Total Anatomical and Physiologic Disease Burdens and Their Prognostic Implications in Patients With Coronary Artery Disease

Chee Hae Kim, Bon-Kwon Koo, Joo Myung Lee, Eun-Seok Shin, Jonghanne Park, Ki Hong Choi, Doyeon Hwang, Tae-Min Rhee, Jinlong Zhang, You-Jung Choi, Seo-Young Lee, Jin-Ho Choi, Joon-Hyung Doh, Chang-Wook Nam, Jianan Wang, Shaoliang Chen, Shoichi Kuramitsu, Nobuhiro Tanaka, Hitoshi Matsuo, Takashi Akasaka, Chee Hae Kim, Bon-Kwon Koo, Joo Myung Lee, Eun-Seok Shin, Jonghanne Park, Ki Hong Choi, Doyeon Hwang, Tae-Min Rhee, Jinlong Zhang, You-Jung Choi, Seo-Young Lee, Jin-Ho Choi, Joon-Hyung Doh, Chang-Wook Nam, Jianan Wang, Shaoliang Chen, Shoichi Kuramitsu, Nobuhiro Tanaka, Hitoshi Matsuo, Takashi Akasaka

Abstract

Background Total atherosclerosis disease burden is associated with clinical outcomes in patients with coronary artery disease. However, the influence of sex on the relationship between total anatomical and physiologic disease burdens and their prognostic implications have not been well defined. Methods and Results A total of 1136 patients who underwent fractional flow reserve (FFR) measurement in all 3 major coronary arteries were included in this study. Anatomical and physiologic total disease burden was assessed by SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score, residual SYNTAX score, a total sum of FFR in 3 vessels (3-vessel FFR), and functional SYNTAX score. The primary end point was major adverse cardiac events, a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization at 2 years. There were no differences in angiographic diameter stenosis, SYNTAX score, or residual SYNTAX score between women and men. However, both per-vessel FFR (0.89±0.10 versus 0.87±0.11, P<0.001) and 3-vessel FFR (2.72±0.13 versus 2.69±0.15, P<0.001) were higher in women. Multivariable Cox regression analyses showed that total anatomical and physiologic disease burdens were significantly associated with 2-year major adverse cardiac events, and there was no significant interaction between sex and total disease burden for clinical outcomes. Conclusions Despite similar angiographic disease severity, both per-vessel and per-patient physiologic disease severity was less in women than in men. There was no influence of sex on prognostic implications of total anatomical and physiologic disease burdens in patients with coronary artery disease. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT01621438.

Keywords: SYNTAX score; coronary artery disease; fractional flow reserve; prognosis; sex; total disease burden.

Figures

Figure 1
Figure 1
Distribution of angiographic percentage diameter stenosis and per‐vessel FFR. The distributions of percentage diameter stenosis (A) and per‐vessel FFR (B) according to sex are presented. FFR indicates fractional flow reserve.
Figure 2
Figure 2
Association between angiographic stenosis severity and FFR according to sex. A, This figure shows the values of FFR according to different angiographic stenosis severity in women and men. B, When the proportions of concordant normal, concordant abnormal, reverse mismatch, and mismatch were compared, mismatch was more frequent in women than in men. %DS indicates percentage diameter stenosis; FFR, fractional flow reserve.
Figure 3
Figure 3
Distributions of SYNTAX Score (A), residual SYNTAX score (B), and 3‐vessel FFR (C) in women and men. There were no differences in SYNTAX score and residual SYNTAX score between women and men. However, 3‐vessel FFR was higher in women (2.72±0.13 vs 2.69±0.15, P<0.001). FFR indicates fractional flow reserve; SYNTAX, Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery.
Figure 4
Figure 4
Association between estimated 2‐year major adverse cardiac event rate and anatomical and physiologic disease burden. SYNTAX score (A), residual SYNTAX score (B), and 3‐vessel FFR (C) showed significant association with the estimated 2‐year MACE rates in both sexes. There was no significant interaction of sex in the relationship between total disease burden and clinical outcomes. FFR indicates fractional flow reserve; HR, hazard ratio; MACE, major adverse cardiovascular events; SYNTAX, Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery.

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