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      Nonobstructive Coronary Artery Disease in Women: Risk Factors and Noninvasive Diagnostic Assessment

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          Abstract

          Sex-specific differences in the epidemiology and pathophysiology of coronary artery disease and ischemic heart disease are now well recognized. Women with angina more often have nonobstructive coronary artery disease (NOCAD) compared with men. This patient population carries a significant risk of future cardiovascular events that is not commonly appreciated, often leading to delayed diagnosis and treatment. While coronary microvascular dysfunction plays a central role in the pathophysiology of NOCAD in women, other mechanisms of myocardial ischemia are now recognized. Risk factors such as hypertension and obesity disparately affect women and are likely to account for a significant proportion of NOCAD in the coming years. Vascular inflammation is an important pathophysiologic pathway in NOCAD and is a potential therapeutic target. Coronary CT angiography provides a comprehensive assessment of coronary anatomy and plaque morphology and is a reasonable screening test of choice for NOCAD.

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          Most cited references 79

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          Prevalence of Obesity Among Adults and Youth: United States, 2015-2016.

          Obesity is associated with serious health risks. Monitoring obesity prevalence is relevant for public health programs that focus on reducing or preventing obesity. Between 2003–2004 and 2013–2014, there were no significant changes in childhood obesity prevalence, but adults showed an increasing trend. This report provides the most recent national estimates from 2015–2016 on obesity prevalence by sex, age, and race and Hispanic origin, and overall estimates from 1999–2000 through 2015–2016.
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            A prospective study of obesity and risk of coronary heart disease in women.

            We examined the incidence of nonfatal and fatal coronary heart disease in relation to obesity in a prospective cohort study of 115,886 U.S. women who were 30 to 55 years of age in 1976 and free of diagnosed coronary disease, stroke, and cancer. During eight years of follow-up (775,430 person-years), we identified 605 first coronary events, including 306 nonfatal myocardial infarctions, 83 deaths due to coronary heart disease, and 216 cases of confirmed angina pectoris. A higher Quetelet index (weight in kilograms divided by the square of the height in meters) was positively associated with the occurrence of each category of coronary heart disease. For increasing levels of current Quetelet index (less than 21, 21 to less than 23, 23 to less than 25, 25 to less than 29, and greater than or equal to 29), the relative risks of nonfatal myocardial infarction and fatal coronary heart disease combined, as adjusted for age and cigarette smoking, were 1.0, 1.3, 1.3, 1.8, and 3.3 (Mantel-extension chi for trend = 7.29; P less than 0.00001). As expected, control for a history of hypertension, diabetes mellitus, and hypercholesterolemia--conditions known to be biologic effects of obesity--attenuated the strength of the association. The current Quetelet index was a more important determinant of coronary risk than that at the age of 18; an intervening weight gain increased risk substantially. These prospective data emphasize the importance of obesity as a determinant of coronary heart disease in women. After control for cigarette smoking, which is essential to assess the true effects of obesity, even mild-to-moderate overweight increased the risk of coronary disease in middle-aged women.
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              Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study.

              The purpose of this study was to investigate the 2-year outcome of percutaneous coronary intervention (PCI) guided by fractional flow reserve (FFR) in patients with multivessel coronary artery disease (CAD). In patients with multivessel CAD undergoing PCI, coronary angiography is the standard method for guiding stent placement. The FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study showed that routine FFR in addition to angiography improves outcomes of PCI at 1 year. It is unknown if these favorable results are maintained at 2 years of follow-up. At 20 U.S. and European medical centers, 1,005 patients with multivessel CAD were randomly assigned to PCI with drug-eluting stents guided by angiography alone or guided by FFR measurements. Before randomization, lesions requiring PCI were identified based on their angiographic appearance. Patients randomized to angiography-guided PCI underwent stenting of all indicated lesions, whereas those randomized to FFR-guided PCI underwent stenting of indicated lesions only if the FFR was 0.80, the rate of myocardial infarction was 0.2% and the rate of revascularization was 3.2 % after 2 years. Routine measurement of FFR in patients with multivessel CAD undergoing PCI with drug-eluting stents significantly reduces mortality and myocardial infarction at 2 years when compared with standard angiography-guided PCI. (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation [FAME]; NCT00267774). Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                CVIA
                Cardiovascular Innovations and Applications
                CVIA
                Compuscript (Ireland )
                2009-8782
                2009-8618
                February 2019
                February 2019
                : 3
                : 4
                : 349-361
                Affiliations
                1Tulane University Heart and Vascular Institute, Tulane University School of Medicine, 1430 Tulane Avenue, SL-8548, New Orleans, LA 70112, USA
                Author notes
                Correspondence: Rohan Samson, MD, Tulane University Heart and Vascular Institute, Tulane University School of Medicine, 1430 Tulane Avenue, SL-8548, New Orleans, LA 70112, USA, Tel.: +1-504-9885152, Fax: +1-504-9884237, E-mail: rsamson@ 123456tulane.edu
                Article
                cvia20170077
                10.15212/CVIA.2017.0077
                Copyright © 2019 Cardiovascular Innovations and Applications

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

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