P539Coronary CT angiography in women and men suspected of acute coronary syndrome in the era of hs-troponins

Abstract

Background: The burden of coronary artery disease (CAD) in women may still be under‐recognized. This might be the result of distinct pathophysiological differences or disease perception by patients and physicians. In this pre‐specified subanalysis of the Better Evaluation of Acute Chest Pain with Coronary Computed Tomography Angiography (BEACON) trial, we compare the clinical effectiveness of early coronary CT angiography (CCTA) in women and men. Methods: In the BEACON‐trial, we randomized 500 patients suspected of ACS (47% women) at the emergency departments (ED) of 7 hospitals to either a diagnostic strategy supplemented by early CCTA or standard optimal care (SOC) with high‐sensitivity troponins (hs‐troponins) available in both groups. To assess interactions between sex and diagnostic group we used logistic regression analysis for binary outcomes and linear regression analysis for continuous outcomes. Results: Obstructive coronary artery disease (CAD) on CCTA (>50% luminal narrowing) was less frequent in women than in men (14% versus 29%, p<0.01). Regardless of group, women were admitted less often (33% versus 43%, p=0.02) and had a shorter length of stay than men (p=0.04). At discharge, ACS was diagnosed less often in women (5% versus 10%, p=0.03). The use of coronary angiography and the rate of coronary revascularization was not statistically different for women regardless of diagnostic strategy. Moreover, no significant interaction was found for the number of hospital admissions, length of stay, repeat ED visits or outpatient testing between sexes and diagnostic groups (all p‐interactions >0.05). Discussion: Previously, it has been shown that early CCTA may be a more efficient work‐up for suspected ACS, especially in women. However, at the same time concerns exist about radiation associated cancer in young women resulting from increased exposure to radiation from medical testing. Our results show indeed a lower incidence of obstructive CAD and ACS in women, however no additional benefit of CCTA could be demonstrated. Novel to prior reports was the availability of hs‐troponins for clinical decision making in both groups. The majority of patients in the current study (>90%) had normal hs‐troponin levels (<99th percentile of the upper limit of normal). It has been shown that these patients have a very low risk of ACS. Further advanced testing, in the form of CCTA, might therefor not be needed for them, and this is regardless of sex. Secondly, it is believed that less classical causes of angina such as endothelial dysfunction and microvascular disease are more relevant in women, while epicardial CAD is more prevalent in men. Consequently, it is likely that CCTA as a anatomic modality would provide less benefit in women following this pathophysiological hypothesis.