Sex-based impact of carotid plaque in patients with chest pain undergoing stress echocardiography

Heart. 2020 Dec;106(23):1819-1823. doi: 10.1136/heartjnl-2019-316507. Epub 2020 May 22.

Abstract

Objective: Women with suspected angina without history of coronary artery disease (CAD) less frequently have flow-limiting stenosis (FL-CAD) and more often have microvascular disease, affecting predictive accuracy of stress echocardiography (SE) for detection of FL-CAD. We postulated that carotid plaque burden (CPB) assessment would improve detection of FL-CAD and risk stratification.

Methods: Consecutive consenting patients assessed by SE on clinical grounds for new-onset chest pain also underwent simultaneous carotid ultrasound. Patients were followed for major adverse events (MAE): all-cause mortality, non-fatal myocardial infarction and unplanned revascularisation. Carotid plaque presence and burden (CPB) were assessed.

Results: After a mean of 2617±469 days (range 17-3740), of 591 recruited patients, 573 (97%) outcome data (314 females) were obtainable. Despite lower pretest probability of CAD in females versus males (14.9±0.8 vs 20.5±1.3, respectively, p<0.0001), prevalence of myocardial ischaemia was similar (p=0.08). Females also had lower prevalence of both carotid plaque (p<0.0001) and FL-CAD (p<0.05). CPB improved the positive predictive value of SE for detection of FL-CAD (from 34.5% to 60%) in females but not in males. Absence of CPB in females with myocardial ischaemia ruled out FL-CAD in 93% versus 57% in males. CPB was the only independent predictor of MAE (p=0.012) in females, whereas in males both SE (p<0.0001) and CPB (p=0.003) remained significant.

Conclusion: In females with new-onset stable angina without a history of cardiovascular disease, CPB improved the predictive accuracy of myocardial ischaemia for flow-limiting CAD. However, CPB provided incremental risk stratification in both sexes.

Keywords: carotid disease; coronary artery disease; echocardiography.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Angina, Stable / diagnosis*
  • Carotid Artery Diseases / diagnostic imaging*
  • Carotid Intima-Media Thickness / statistics & numerical data
  • Coronary Artery Disease* / complications
  • Coronary Artery Disease* / diagnosis
  • Coronary Artery Disease* / mortality
  • Coronary Artery Disease* / physiopathology
  • Echocardiography, Stress* / methods
  • Echocardiography, Stress* / statistics & numerical data
  • Female
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Microvascular Angina
  • Middle Aged
  • Myocardial Infarction* / epidemiology
  • Myocardial Infarction* / etiology
  • Myocardial Infarction* / therapy
  • Myocardial Revascularization / statistics & numerical data
  • Plaque, Atherosclerotic / diagnostic imaging*
  • Predictive Value of Tests
  • Risk Assessment / methods
  • Risk Factors
  • Sex Factors
  • United Kingdom / epidemiology