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Original research
Sex-based impact of carotid plaque in patients with chest pain undergoing stress echocardiography
  1. Shahram Ahmadvazir1,2,
  2. Jiwan Pradhan1,
  3. Rajdeep Singh Khattar2,
  4. Roxy Senior1,2
  1. 1 Department of Cardiovascular Research, Northwick Park Hospital, Harrow, UK
  2. 2 Department of Cardiology, Royal Brompton Hospital, London, UK
  1. Correspondence to Professor Roxy Senior, Department of Cardiology, Royal Brompton Hospital, London SW3 6NP, UK; roxysenior{at}


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

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

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

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

  • coronary artery disease
  • carotid disease
  • echocardiography

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  • Contributors SA: designing and planning, patient recruitment, data collection, data analysis, statistical analysis, draft and final manuscript. JP: data collection, data analysis, draft and final manuscript. RSK: data analysis, draft and final manuscript. RS: designing and planning, conduct of draft and final manuscript, responsible for the overall content.

  • Funding The Northwick Park Cardiovascular Research department funded this study.

  • Competing interests RS has received speaker fees/honorarium from Bracco, Milan, Italy, and Philips, Eindhoven, Netherlands.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The local research ethical committee approved the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Protocol, statistical analysis plan and raw data set will be available upon receiving reasonable request.