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Open Access 06-08-2021 | Original Article

Coronary CT angiography for suspected acute coronary syndrome: sex-associated differences

Auteurs: M. Arslan, J. Schaap, A. Moelker, P. P. M. Rood, E. Boersma, K. Nieman, E. A. Dubois, A. Dedic

Gepubliceerd in: Netherlands Heart Journal | Uitgave 10/2021

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Abstract

Aim

The optimal diagnostic test in the work-up of suspected acute coronary syndrome (ACS) may differ between men and women. The aim of this study was to compare sex-associated differences between using a diagnostic strategy including early coronary computed tomography angiography (CCTA) and standard of care (SOC).

Methods

In total, 500 patients who presented with symptoms suggestive of ACS at the emergency department were randomised between a diagnostic strategy supplemented with early CCTA and SOC.

Results

Women were generally older than men (mean ± standard deviation 56 ± 10 vs 53 ± 10 years, p < 0.01) and were less often admitted to hospital (33% vs 44%, p = 0.02). Obstructive coronary artery disease on CCTA (> 50% luminal narrowing) was less frequently seen in women (14% vs 26%, p = 0.02), and ACS was diagnosed less often in women (5% vs 10%, p = 0.03). Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS (p = 0.008).

Conclusion

Women had a lower incidence of obstructive CAD on CCTA and were less often admitted to hospital than men. They were subjected to less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS.
Opmerkingen

Supplementary Information

The online version of this article (https://​doi.​org/​10.​1007/​s12471-021-01607-1) contains supplementary material, which is available to authorized users.
What’s new?
  • In this study in patients with suspected acute coronary syndrome (ACS), women had a lower incidence of obstructive coronary artery disease on coronary computed tomography angiography (CCTA) than men.
  • Women were less often admitted to hospital than men.
  • Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS than men.

Introduction

There are distinct pathophysiological differences in coronary artery disease (CAD) between men and women. Men are more likely to have obstructive epicardial CAD, while women are more prone to have coronary microvascular dysfunction [1]. In addition, disease perception may differ, both from the physician’s perspective—leading to sex-specific referral bias—and the patient’s own perception of chest discomfort, both of which can result in underrecognition of the burden of CAD in women [2]. The optimal diagnostic test in the work-up of suspected acute coronary syndrome (ACS) may therefore be different for men and women [3].
In this prespecified subanalysis of the Better Evaluation of Acute Chest Pain with Coronary Computed Tomography Angiography (BEACON) trial, we compared the clinical presentation, coronary computed tomography angiography (CCTA) results and the subsequent effect on downstream healthcare utilisation in men and women with suspected ACS.

Methods

The study design, the criteria for enrolment and the primary results have been reported previously [4]. Briefly, in the BEACON trial, we randomised 500 patients suspected of having ACS (47% women, 79% of whom were evaluated with a high-sensitivity (hs) troponin assay) at the emergency department of seven hospitals to receive either standard of care (SOC) or a diagnostic strategy supplemented with early CCTA. In the SOC group, the attending physicians made clinical decisions regarding further testing, including repeated cardiac marker assessment, hospital admission, noninvasive tests and referral to invasive coronary angiography, according to relevant guidelines [5, 6]. The results of the main study showed that CCTA, which was applied early in the work-up of suspected ACS, is safe and is associated with less outpatient testing and lower costs. Data concerning particular endpoints, including coronary angiography, coronary revascularisation, hospital admission, length of stay, repeat emergency department visit and outpatient testing, were collected within 30 days of follow-up.
In the current analysis, non–sex-specific 99th percentile upper reference limits of normal were used for all troponin assays, conventional or high-sensitivity, with the exception of the Hs-TnI assay (Abbott ARCHITECT, Abbott Laboratories, Chicago, IL, USA), for which vendor-recommended sex-specific cut-off values were used. ACS was defined as either unstable angina pectoris or myocardial infarction (MI), according to the Third Universal Definition of MI [7].

Statistical analysis

Continuous data are presented as mean ± standard deviation or median (interquartile range), and categorical data are presented as proportion (percentage). Differences between independent groups were compared using the analysis of variance or the Mann-Whitney U test for continuous variables, and the Fisher’s exact test or the Pearson’s chi-square test for categorical variables. All tests were two-tailed and a p-value < 0.05 was considered statistically significant. The study was conducted according to the principles of the Declaration of Helsinki and approved by the local institutional review boards. All patients provided written informed consent. The trial was registered at ClinicalTrials.gov (NCT01413282).

Results

In the BEACON trial, women were generally older than men (56 ± 10 vs 53 ± 10 years, p < 0.01), less often active smokers and received less pharmacological treatment (Tab. 1). Table S1 in the Electronic Supplementary Material lists all troponin assays used, their characteristics and the algorithm with which they were implemented. ACS was less often diagnosed in women than in men (5% vs 10%, p = 0.03), and obstructive CAD on CCTA (> 50% luminal narrowing) was less frequently seen in women (14% vs 26%, p < 0.02).
Table 1
Baseline characteristics and study outcomes
Variable
Women
(n = 236)
Men
(n = 264)
P-value
Age, years
 56 ± 10
 53 ± 10
< 0.01
Medication
Statin
 43 (18.2)
 73 (27.7)
  0.01
Aspirin
 35 (14.8)
 48 (18.2)
  0.32
Beta blocker
 45 (19.1)
 36 (13.6)
  0.10
ACE inhibitor
 23 (9.7)
 35 (13.3)
  0.22
Angiotensin receptor blocker
 23 (9.7)
 12 (4.5)
  0.02
Calcium channel blocker
 21 (8.9)
 16 (6.1)
  0.23
Diuretic agent
 37 (15.7)
 22 (8.3)
  0.01
Cardiovascular risk factors
Diabetes mellitus
 25 (10.6)
 39 (14.8)
  0.16
Hypertension
102 (43.2)
119 (45.1)
  0.68
Dyslipidaemia
 76 (32.2)
101 (38.3)
  0.15
Smoking (active)
 65 (27.5)
106 (40.2)
< 0.01
Family history
101 (42.8)
109 (41.3)
  0.73
GRACE score
 85 ± 24
 85 ± 25
  0.96
CCTA assessment of CAD
  
  0.02
Non-obstructive CAD
No stenosis
 59 (48.4)
 49 (39.2)
 
< 20% stenosis
 13 (10.7)
 12 (9.6)
 
  20–49% stenosis
 23 (18.9)
 23 (18.4)
 
Obstructive CAD
  50–69% stenosis
 13 (10.7)
 23 (18.4)
 
> 70 stenosis
  4 (3.3)
 10 (8.0)
 
Non-diagnostic
 10 (8.2)
  8 (6.4)
 
Outcomes
Coronary angiography
 27 (11.4)
 45 (17.0)
  0.07
Coronary revascularisation
 15 (6.4)
 24 (9.1)
  0.25
ACS
 12 (5.1)
 27 (10.2)
  0.03
Unstable angina
  5 (2.1)
  6 (2.3)
  0.91
Myocardial infarction
  7 (3.0)
 21 (8.0)
  0.02
Hospital admission
 77 (32.6)
110 (41.7)
  0.04
Length of stay, hours
  6.1 (4.5–15.0)
  7.0 (4.7–24.5)
  0.21
Repeat ED visit
 17 (7.2)
 15 (5.7)
  0.49
Outpatient testinga
 18 (7.6)
 18 (6.8)
  0.74
Baseline troponin level ≥ 99th percentile and non-obstructive CAD on CCTA
  1 (0.4)
  4 (1.5)
  1.00
Values are mean ± standard deviation, n (%) or median (interquartile range)
ACE angiotensin-converting enzyme, GRACE Global Registry of Acute Coronary Events, CCTA coronary computed tomography angiography, CAD coronary artery disease, ACS acute coronary syndrome, ED emergency department
a Outpatient testing consists of following cardiac tests: exercise electrocardiography, single-photon emission computed tomography, cardiac magnetic resonance imaging, coronary computed tomography angiography and invasive coronary angiography
Women were admitted less often (33% vs 42%, p = 0.04). The use of invasive coronary angiography (11% vs 17%, p = 0.07) and the rate of coronary revascularisation (6% vs 9%, p = 0.25) were not statistically different between women and men, although referral to invasive coronary angiography was numerically higher in men (Tab. 1).
Tab. 2 shows the study endpoints when comparing both diagnostic groups based on sex. Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS (p = 0.008).
Table 2
Study outcomes stratified by diagnostic group
Variable
SOC arm:
women (n = 113);
men (n = 137)
CCTA arm:
women (n = 123);
men (n = 127)
P-value
Coronary angiography
Women
11 (9.7)
16 (13.0)
0.43
Men
20 (14.6)
25 (19.7)
0.26
Coronary revascularisation
Women
 6 (5.3)
 9 (7.3)
0.53
Men
11 (8.0)
13 (10.2)
0.52
ACS at discharge
Women
 5 (4.4)
 7 (5.7)
0.66
Men
12 (8.8)
15 (11.8)
0.41
Unstable angina at discharge
Women
 1 (0.9)
 4 (3.3)
0.21
Men
 2 (1.5)
 4 (3.1)
0.36
Myocardial infarction at discharge
Women
 4 (3.5)
 3 (2.4)
0.62
Men
10 (7.3)
11 (8.7)
0.68
Hospital admission
Women
40 (35.4)
37 (30.1)
0.38
Men
64 (46.7)
49 (38.6)
0.33
Length of stay
Women
 6.0 (4.4–21.9)
 6.3 (4.7–10.6)
0.58
Men
 7.1 (4.5–27.1)
 6.3 (4.8–17.4)
0.78
Repeat ED visit
Women
11 (9.7)
 6 (4.9)
0.15
Men
 8 (5.8)
 7 (5.5)
0.91
Outpatient testinga
Women
14 (12.4)
 4 (3.3)
0.008
Men
12 (8.8)
 6 (4.8)
0.2
Values are n (%) or median (interquartile range)
SOC standard of care, CCTA coronary computed tomography angiography, ACS acute coronary syndrome, ED emergency department
a Outpatient testing consists of following cardiac tests: exercise electrocardiography, single-photon emission computed tomography, cardiac magnetic resonance imaging, coronary computed tomography angiography and invasive coronary angiography
Tab. 3 shows the study endpoints when comparing both sexes within each diagnostic group. In the CCTA arm, men were more likely to be diagnosed with MI at discharge than women (p = 0.03). Furthermore, although not statistically significant, in the SOC arm, women were less likely to be admitted to hospital (p = 0.07) and had a shorter length of stay (p = 0.08) than men.
Table 3
Study outcomes stratified by sex
Variable
Women:
SOC arm (n = 113);
CCTA arm(n = 123)
Men:
SOC arm (n = 137);
CCTA arm (n = 127)
P-value
Coronary angiography
SOC arm
11 (9.7)
20 (14.6)
0.25
CCTA arm
16 (13.0)
25 (19.8)
0.15
Coronary revascularisation
SOC arm
 6 (5.3)
11 (8.0)
0.40
CCTA arm
 9 (7.3)
13 (10.3)
0.40
ACS at discharge
SOC arm
 5 (4.4)
12 (8.8)
0.18
CCTA arm
 7 (5.7)
15 (11.8)
0.09
Unstable angina at discharge
SOC arm
 1 (0.9)
 2 (1.5)
0.68
CCTA arm
 4 (3.3)
 4 (3.1)
0.96
Myocardial infarction at discharge
SOC arm
 4 (3.5)
10 (7.3)
0.20
CCTA arm
 3 (2.4)
11 (8.7)
0.03
Hospital admission
SOC arm
40 (35.4)
64 (46.7)
0.07
CCTA arm
37 (30.1)
49 (38.6)
0.16
Length of stay
SOC arm
 6.0 (4.4–21.9)
 7.1 (4.5–27.1)
0.08
CCTA arm
 6.3 (4.7–10.6)
 6.3 (4.8–17.4)
0.70
Repeat ED visit
SOC arm
11 (9.7)
 8 (5.8)
0.25
CCTA arm
 6 (4.9)
 7 (5.5)
0.82
Outpatient testinga
SOC arm
14 (12.4)
12 (8.8)
0.35
CCTA arm
 4 (3.3)
 6 (4.8)
0.54
Values are median (interquartile range) or n (%)
SOC standard of care, CCTA coronary computed tomography angiography, ACS acute coronary syndrome, ED emergency department
a Outpatient testing consists of following cardiac tests: exercise electrocardiography, single-photon emission computed tomography, cardiac magnetic resonance imaging, coronary computed tomography angiography and invasive coronary angiography

Discussion

In this prespecified analysis of the BEACON trial, women had a lower incidence of obstructive CAD on CCTA and were less often admitted to hospital than men. Women also underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS. Although not statistically significant, in the SOC arm, women were less likely to be admitted to hospital and had a shorter length of stay than men.
The presence of sex differences in the pathophysiology of ischaemic heart disease is becoming increasingly apparent [8, 9]. Previously, it has been shown that early CCTA may be a more efficient work-up for suspected ACS, especially in women. In a study by Truong et al., women showed a greater reduction in length of stay and hospital admission than men when early CCTA was used in the emergency department evaluation of suspected ACS [10]. The lower burden of CAD in women was thought to be a likely explanation for this difference, as physicians felt less need to perform downstream tests in patients with non-obstructive CAD on CCTA [10]. Although, we did not see similar reductions in hospital admission and length of stay, women underwent less outpatient testing than men when early CCTA was used. This reduction may also be due to the fact that women had a lower burden of CAD on CCTA, which in turn more often reassured physicians not to perform outpatient testing compared with men.
Although patients with angina without obstructive CAD have a better prognosis than those with obstructive epicardial CAD, they are still at higher risk of cardiovascular disease outcomes than the background population. Therefore, physicians should be vigilant in patients with recurring angina without obstructive epicardial CAD, especially in women, and initiate further evaluation of microvascular disease and treat accordingly.
A novelty in our study was the availability of hs-troponins for clinical decision-making in most of the patients. The introduction of hs-troponin assays has altered our perspective on MI and the way we practice medicine. These new cardiac biomarkers pick up myocardial injury fast and very precisely; serial low values almost certainly exclude MI [11, 12]. In the current study, the majority of the patients with available hs-troponins (> 90%) had normal levels (< 99th percentile of the upper limit of normal), which reassured treating physicians to discharge patients expeditiously, regardless of sex.
However, the improved sensitivity of these new biomarker assays has led to an increasing number of patients being diagnosed with myocardial injury causa ignota. Myocardial injury can be the result of type I MI associated with coronary plaque disruption or other types of MI, non-coronary heart disease or even non-cardiac diseases. Myocardial injury, irrespective of the cause, is associated with a less favourable prognosis and there are also sex-specific differences regarding the cause of injury [1315]. Although this type of conclusions cannot be drawn from our own data, it is believed that women more often have other conditions than obstructive epicardial CAD that cause myocardial injury, such as coronary vasospasm or dissection [16, 17]. As a noninvasive anatomical modality, CCTA can serve as a gatekeeper of traditional coronary angiography by discriminating between obstructive and non-obstructive epicardial CAD.

Study limitations

The current study does have some limitations that need to be highlighted. We have presented short-term data, but outpatient testing could also have taken place more than 30 days after the index presentation. In addition, the heterogeneity of troponin assays implemented in the current study could have impacted the diagnostic process and the downstream healthcare utilisation for both women and men. Finally, due to conflicting evidence and a lack of universally accepted sex-specific 99th percentile cut-offs, we were unable to implement sex-specific cut-offs for certain assays used in this study, with the exception of the hs-TnI assay (Abbott ARCHITECT).

Conclusion

Compared with men, women had a lower incidence of obstructive CAD on CCTA, were less often admitted and underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS.

Acknowledgements

We thank medical personnel at all participating centres who made this study possible.

Funding

This work was supported by a grant from the Erasmus University Medical Centre and a research grant from the Erasmus MC Thorax Foundation (project grant B4).

Conflict of interest

M. Arslan, J. Schaap, A. Moelker, P. P. M. Rood, E. Boersma, E. A. Dubois and A. Dedic declare that they have no competing interests. K. Nieman has received a grant from the Dutch Heart Foundation (NHS 2014T061) and grants from Siemens Medical Solutions, GE Healthcare, Bayer Healthcare and HeartFlow outside the submitted work.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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Literatuur
1.
go back to reference Taqueti VR, Shaw LJ, Cook NR, et al. Excess cardiovascular risk in women relative to men referred for coronary angiography is associated with severely impaired coronary flow reserve, not obstructive disease. Circulation. 2017;135:566–77.CrossRef Taqueti VR, Shaw LJ, Cook NR, et al. Excess cardiovascular risk in women relative to men referred for coronary angiography is associated with severely impaired coronary flow reserve, not obstructive disease. Circulation. 2017;135:566–77.CrossRef
2.
go back to reference Douglas PS, Ginsburg GS. The evaluation of chest pain in women. N Engl J Med. 1996;334:1311–5.CrossRef Douglas PS, Ginsburg GS. The evaluation of chest pain in women. N Engl J Med. 1996;334:1311–5.CrossRef
3.
go back to reference Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682–96.CrossRef Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682–96.CrossRef
4.
go back to reference Dedic A, Lubbers MM, Schaap J, et al. Coronary CT angiography for suspected ACS in the era of high-sensitivity troponins: randomized multicenter study. J Am Coll Cardiol. 2016;67:16–26.CrossRef Dedic A, Lubbers MM, Schaap J, et al. Coronary CT angiography for suspected ACS in the era of high-sensitivity troponins: randomized multicenter study. J Am Coll Cardiol. 2016;67:16–26.CrossRef
5.
go back to reference Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;64:e139–e228.CrossRef Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;64:e139–e228.CrossRef
6.
go back to reference Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:2999–3054.CrossRef Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:2999–3054.CrossRef
7.
go back to reference Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581–98.CrossRef Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581–98.CrossRef
8.
go back to reference Berger JS, Elliott L, Gallup D, et al. Sex differences in mortality following acute coronary syndromes. JAMA. 2009;302:874–82.CrossRef Berger JS, Elliott L, Gallup D, et al. Sex differences in mortality following acute coronary syndromes. JAMA. 2009;302:874–82.CrossRef
9.
go back to reference Chokshi NP, Iqbal SN, Berger RL, et al. Sex and race are associated with the absence of epicardial coronary artery obstructive disease at angiography in patients with acute coronary syndromes. Clin Cardiol. 2010;33:495–501.CrossRef Chokshi NP, Iqbal SN, Berger RL, et al. Sex and race are associated with the absence of epicardial coronary artery obstructive disease at angiography in patients with acute coronary syndromes. Clin Cardiol. 2010;33:495–501.CrossRef
10.
go back to reference Truong QA, Hayden D, Woodard PK, et al. Sex differences in the effectiveness of early coronary computed tomographic angiography compared with standard emergency department evaluation for acute chest pain: the rule-out myocardial infarction with Computer-Assisted Tomography (ROMICAT)-II Trial. Circulation. 2013;127:2494–502.CrossRef Truong QA, Hayden D, Woodard PK, et al. Sex differences in the effectiveness of early coronary computed tomographic angiography compared with standard emergency department evaluation for acute chest pain: the rule-out myocardial infarction with Computer-Assisted Tomography (ROMICAT)-II Trial. Circulation. 2013;127:2494–502.CrossRef
11.
go back to reference Mokhtari A, Borna C, Gilje P, et al. A 1‑h combination algorithm allows fast rule-out and rule-in of major adverse cardiac events. J Am Coll Cardiol. 2016;67:1531–40.CrossRef Mokhtari A, Borna C, Gilje P, et al. A 1‑h combination algorithm allows fast rule-out and rule-in of major adverse cardiac events. J Am Coll Cardiol. 2016;67:1531–40.CrossRef
12.
go back to reference Reichlin T, Twerenbold R, Wildi K, et al. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. Cmaj. 2015;187:E243–E52.CrossRef Reichlin T, Twerenbold R, Wildi K, et al. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. Cmaj. 2015;187:E243–E52.CrossRef
13.
go back to reference Barr PR, Harrison W, Smyth D, Flynn C, Lee M, Kerr AJ. Myocardial infarction without obstructive coronary artery disease is not a benign condition (ANZACS-QI 10). Heart Lung Circ. 2018;27:165–74.CrossRef Barr PR, Harrison W, Smyth D, Flynn C, Lee M, Kerr AJ. Myocardial infarction without obstructive coronary artery disease is not a benign condition (ANZACS-QI 10). Heart Lung Circ. 2018;27:165–74.CrossRef
14.
go back to reference Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015;131:861–70.CrossRef Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015;131:861–70.CrossRef
15.
go back to reference Smilowitz NR, Mahajan AM, Roe MT, et al. Mortality of myocardial infarction by sex, age, and obstructive coronary artery disease status in the ACTION registry-GWTG (acute coronary treatment and intervention outcomes network registry-get with the guidelines). Circ Cardiovasc Qual Outcomes. 2017;10:e3443.CrossRef Smilowitz NR, Mahajan AM, Roe MT, et al. Mortality of myocardial infarction by sex, age, and obstructive coronary artery disease status in the ACTION registry-GWTG (acute coronary treatment and intervention outcomes network registry-get with the guidelines). Circ Cardiovasc Qual Outcomes. 2017;10:e3443.CrossRef
16.
go back to reference Harmony RR, Monvadi BS, Sohah NI, et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation. 2011;124:1414–25.CrossRef Harmony RR, Monvadi BS, Sohah NI, et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation. 2011;124:1414–25.CrossRef
17.
go back to reference Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation. 2012;126:579–88.CrossRef Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation. 2012;126:579–88.CrossRef
Metagegevens
Titel
Coronary CT angiography for suspected acute coronary syndrome: sex-associated differences
Auteurs
M. Arslan
J. Schaap
A. Moelker
P. P. M. Rood
E. Boersma
K. Nieman
E. A. Dubois
A. Dedic
Publicatiedatum
06-08-2021
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 10/2021
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-021-01607-1

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