54 Chapter 3 Limitations First, despite the length of follow-up and the large number of included patients, the results should be interpreted considering the basic limitations of a retrospective registry. Second, the number of female patients is the current study is limited compared to the number of male patients. Although this an observational study and thereby a presentation of the contemporary clinical practice, these results should be interpreted with the historical underrepresentation of female patients diagnosed with coronary artery disease. Third, although the MRR is an index that can be derived by any robust flow-measuring technique, uniform application of continuous flow, as used in the initial derivation of MRR, may further enhance its diagnostic and prognostic value considering the operator-independent nature of this absolute flow measurements. Conclusion This study is the first to specifically assess the diagnostic and prognostic characteristics of the MRR in female patients. Despite the theoretical limitations of the MRR in female patients, there was no considerable difference in the diagnostic characteristics and the prognostic value of the MRR across sexes. As such, the MRR seems to be equally applicable in both women and men with CCS and could enhance the diagnostic yield of CMD interrogation in contemporary clinical practice. Future studies are warranted to address the potential of sex-specific decision-making thresholds using MRR.
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