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Prognostic Significance of Nonobstructive Left Main Coronary Artery Disease in Women Versus Men: Long-Term Outcomes From the CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter) Registry.
Circ Cardiovasc Imaging. 2017 Aug; 10(8)CC

Abstract

BACKGROUND

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.

METHODS AND RESULTS

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%; P<0.0001); men (24.6% versus 18.2%; P<0.0001). A significant interaction existed between sex and LM status for the composite outcome (P=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; P=0.005) but not in men (adjusted hazard ratio, 0.98, P=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; P=0.017); sex-specific interactions were not observed across other patterns (eg, location or extent) of nonobstructive plaque.

CONCLUSION

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.

Authors+Show Affiliations

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.). joe.xie@emory.edu.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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).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.).

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study

Language

eng

PubMed ID

28790123

Citation

Xie, Joe X., et al. "Prognostic Significance of Nonobstructive Left Main Coronary Artery Disease in Women Versus Men: Long-Term Outcomes From the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: an International Multicenter) Registry." Circulation. Cardiovascular Imaging, vol. 10, no. 8, 2017.
Xie JX, Eshtehardi P, Varghese T, et al. Prognostic Significance of Nonobstructive Left Main Coronary Artery Disease in Women Versus Men: Long-Term Outcomes From the CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter) Registry. Circ Cardiovasc Imaging. 2017;10(8).
Xie, J. X., Eshtehardi, P., Varghese, T., Goyal, A., Mehta, P. K., Kang, W., Leipsic, J., Ó Hartaigh, B., Bairey Merz, C. N., Berman, D. S., Gransar, H., Budoff, M. J., Achenbach, S., Callister, T. Q., Marques, H., Rubinshtein, R., Al-Mallah, M. H., Andreini, D., Pontone, G., ... Shaw, L. J. (2017). Prognostic Significance of Nonobstructive Left Main Coronary Artery Disease in Women Versus Men: Long-Term Outcomes From the CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter) Registry. Circulation. Cardiovascular Imaging, 10(8). https://doi.org/10.1161/CIRCIMAGING.117.006246
Xie JX, et al. Prognostic Significance of Nonobstructive Left Main Coronary Artery Disease in Women Versus Men: Long-Term Outcomes From the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: an International Multicenter) Registry. Circ Cardiovasc Imaging. 2017;10(8) PubMed PMID: 28790123.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Prognostic Significance of Nonobstructive Left Main Coronary Artery Disease in Women Versus Men: Long-Term Outcomes From the CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter) Registry. AU - Xie,Joe X, AU - Eshtehardi,Parham, AU - Varghese,Tina, AU - Goyal,Abhinav, AU - Mehta,Puja K, AU - Kang,William, AU - Leipsic,Jonathon, AU - Ó Hartaigh,Bríain, AU - Bairey Merz,C Noel, AU - Berman,Daniel S, AU - Gransar,Heidi, AU - Budoff,Matthew J, AU - Achenbach,Stephan, AU - Callister,Tracy Q, AU - Marques,Hugo, AU - Rubinshtein,Ronen, AU - Al-Mallah,Mouaz H, AU - Andreini,Daniele, AU - Pontone,Gianluca, AU - Cademartiri,Filippo, AU - Maffei,Erica, AU - Chinnaiyan,Kavitha, AU - Raff,Gilbert, AU - Hadamitzky,Martin, AU - Hausleiter,Joerg, AU - Feuchtner,Gudrun, AU - Kaufmann,Philipp A, AU - Villines,Todd C, AU - Chow,Benjamin J W, AU - Min,James K, AU - Shaw,Leslee J, PY - 2017/02/15/received PY - 2017/06/21/accepted PY - 2017/8/10/entrez PY - 2017/8/10/pubmed PY - 2017/8/22/medline KW - coronary computed tomographic angiography KW - incidence KW - left main KW - nonobstructive coronary artery disease KW - sex disparities in coronary heart disease JF - Circulation. Cardiovascular imaging JO - Circ Cardiovasc Imaging VL - 10 IS - 8 N2 - BACKGROUND: 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. METHODS AND RESULTS: 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%; P<0.0001); men (24.6% versus 18.2%; P<0.0001). A significant interaction existed between sex and LM status for the composite outcome (P=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; P=0.005) but not in men (adjusted hazard ratio, 0.98, P=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; P=0.017); sex-specific interactions were not observed across other patterns (eg, location or extent) of nonobstructive plaque. CONCLUSION: 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. SN - 1942-0080 UR - https://www.unboundmedicine.com/medline/citation/28790123/Prognostic_Significance_of_Nonobstructive_Left_Main_Coronary_Artery_Disease_in_Women_Versus_Men:_Long_Term_Outcomes_From_the_CONFIRM__Coronary_CT_Angiography_Evaluation_For_Clinical_Outcomes:_An_International_Multicenter__Registry_ L2 - https://www.ahajournals.org/doi/10.1161/CIRCIMAGING.117.006246?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -