Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Current Cardiology Reports
Published in: Current Cardiology Reports 4/2020

01-04-2020 | Arterial Occlusive Disease | Ischemic Heart Disease (D Mukherjee, Section Editor)

Sex Differences in Coronary Artery Calcium and Long-term CV Mortality

Authors: Allison Bigeh, Chandana Shekar, Martha Gulati

Published in: Current Cardiology Reports | Issue 4/2020

Login to get access

Abstract

Purpose of Review

To summarize differences in plaque depositions, coronary artery calcium (CAC) scoring, and the role of CAC in predicting atherosclerotic cardiovascular disease (ASCVD) mortality in men and women.

Recent Findings

Women have coronary plaque that is more lipid-rich, dense, and less calcified than their male counterparts. CAC scoring has emerged as a useful tool to quantify ASCVD burden. However, recent evidence favors the use of sex-adjusted CAC cutoffs for women to account for the relatively lower overall CAC burden and therefore risk stratify women appropriately. Several studies have identified CAC distribution patterns in women associated with increased CV mortality, particularly the number of lesions involved, CAC volume, and size.

Summary

Multiple studies have shown that the pathophysiology and associated risks of ASCVD are different in women when compared with men. CAC scoring is a tool that is widely being used for ASCVD risk stratification. Recent studies have shown that although men have higher CAC burdens, women are more likely to develop plaque erosions with non-calcified plaque that carries a greater risk for cardiovascular events. Providers should be aware of sex-specific CAC patterns carrying increased mortality risk for women, particularly increasing lesion size and number. Given the differences in plaque composition and distribution, revised sex-adjusted CAC scoring is suggested to better risk stratify patients, especially those deemed intermediate risk, and decrease CV mortality.
Literature
1.
Murphy SL, Xu J, Kochanek KD, Arias E, Mortality in the United States. NCHS. Data Brief. 2017;2018(328):1–8.
2.
Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Van de Werf F, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators. N Engl J Med. 1999;341(4):226–32.CrossRefPubMed
3.
Berger JS, Elliott L, Gallup D, Roe M, Granger CB, Armstrong PW, et al. Sex differences in mortality following acute coronary syndromes. JAMA. 2009;302(8):874–82.CrossRefPubMedPubMedCentral
4.
Canto JG, Rogers WJ, Goldberg RJ, Peterson ED, Wenger NK, Vaccarino V, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813–22.CrossRefPubMedPubMedCentral
5.
Bairey Merz CN, Shaw LJ, Reis SE, Bittner V, Kelsey SF, Olson M, et al. Insights from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study: part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol. 2006;47(3 Suppl):S21–9.CrossRefPubMed
6.
Dey S, Flather MD, Devlin G, Brieger D, Gurfinkel EP, Steg PG, et al. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the global registry of acute coronary events. Heart. 2009;95(1):20–6.CrossRefPubMed
7.
Johnston N, Schenck-Gustafsson K, Lagerqvist B. Are we using cardiovascular medications and coronary angiography appropriately in men and women with chest pain? Eur Heart J. 2011;32(11):1331–6.CrossRefPubMed
8.
Leifheit-Limson EC, D’Onofrio G, Daneshvar M, Geda M, Bueno H, Spertus JA, et al. Sex differences in cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction: the VIRGO study. J Am Coll Cardiol. 2015;66(18):1949–57.CrossRefPubMedPubMedCentral
9.
• Shaw LJ, Min JK, Nasir K, Xie JX, Berman DS, Miedema MD, et al. Sex differences in calcified plaque and long-term cardiovascular mortality: observations from the CAC consortium. Eur Heart J. 2018;39(41):3727–35. This was an important study of sex-specific CAC distribution patterns and long-term CV mortality.CrossRefPubMedPubMedCentral
10.
11.
Pepine CJ, Kerensky RA, Lambert CR, Smith KM, von Mering GO, Sopko G, et al. Some thoughts on the vasculopathy of women with ischemic heart disease. J Am Coll Cardiol. 2006;47(3 Suppl):S30–5.CrossRefPubMed
12.
Jacobs AK. Coronary intervention in 2009: are women no different than men? Circ Cardiovasc Interv. 2009;2(1):69–78.CrossRefPubMed
13.
Sheifer SE, Canos MR, Weinfurt KP, Arora UK, Mendelsohn FO, Gersh BJ, et al. Sex differences in coronary artery size assessed by intravascular ultrasound. Am Heart J. 2000;139(4):649–53.CrossRefPubMed
14.
Han SH, Bae JH, Holmes DR, Lennon RJ, Eeckhout E, Barsness GW, et al. Sex differences in atheroma burden and endothelial function in patients with early coronary atherosclerosis. Eur Heart J. 2008;29(11):1359–69.CrossRefPubMed
15.
Li L, Wang L, Liu SS, Zhao ZY, Li M, Wang TG, et al. Association between coronary atherosclerotic plaque composition and cardiovascular disease risk. Biomed Environ Sci. 2019;32(2):75–86.PubMed
16.
Lee H, Yoon YE, Kim YJ, Kim HL, Lee SP, Kim HK, et al. Presence and extent of coronary calcified plaque evaluated by coronary computed tomographic angiography are independent predictors of ischemic stroke in patients with suspected coronary artery disease. Int J Cardiovasc Imaging. 2015;31(7):1469–78.CrossRefPubMed
17.
Pundziute G, Schuijf JD, Jukema JW, Boersma E, de Roos A, van der Wall EE, et al. Prognostic value of multislice computed tomography coronary angiography in patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2007;49(1):62–70.CrossRefPubMed
18.
Criqui MH, Denenberg JO, Ix JH, McClelland RL, Wassel CL, Rifkin DE, et al. Calcium density of coronary artery plaque and risk of incident cardiovascular events. JAMA. 2014;311(3):271–8.CrossRefPubMedPubMedCentral
19.
Bharadwaj AS, Vengrenyuk Y, Yoshimura T, Baber U, Hasan C, Narula J, et al. Multimodality intravascular imaging to evaluate sex differences in plaque morphology in stable CAD. JACC Cardiovasc Imaging. 2016;9(4):400–7.CrossRefPubMed
20.
Hoffmann U, Massaro JM, Fox CS, Manders E, O’Donnell CJ. Defining normal distributions of coronary artery calcium in women and men (from the Framingham Heart Study). Am J Cardiol. 2008;102(9):1136–41 41.e1.CrossRefPubMedPubMedCentral
21.
Hoshino M, Yonetsu T, Usui E, Kanaji Y, Ohya H, Sumino Y, et al. Clinical significance of the presence or absence of lipid-rich plaque underneath intact fibrous cap plaque in acute coronary syndrome. J Am Heart Assoc. 2019;8(9):e011820.CrossRefPubMedPubMedCentral
22.
ElFaramawy A, Youssef M, Abdel Ghany M, Shokry K. Difference in plaque characteristics of coronary culprit lesions in a cohort of Egyptian patients presented with acute coronary syndrome and stable coronary artery disease: an optical coherence tomography study. Egypt Heart J. 2018;70(2):95–100.CrossRefPubMed
23.
Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005;46(1):158–65.CrossRefPubMed
24.
Becker A, Leber A, Becker C, Knez A. Predictive value of coronary calcifications for future cardiac events in asymptomatic individuals. Am Heart J. 2008;155(1):154–60.CrossRefPubMed
25.
Wang L, Mintz GS, Witzenbichler B, Metzger DC, Rinaldi MJ, Duffy PL, et al. Differences in underlying culprit lesion morphology between men and women: an IVUS analysis from the ADAPT-DES study. JACC Cardiovasc Imaging. 2016;9(4):498–9.CrossRefPubMed
26.
Dai J, Xing L, Jia H, Zhu Y, Zhang S, Hu S, et al. In vivo predictors of plaque erosion in patients with ST-segment elevation myocardial infarction: a clinical, angiographical, and intravascular optical coherence tomography study. Eur Heart J. 2018;39(22):2077–85.CrossRefPubMed
27.
Bentzon JF, Otsuka F, Virmani R, Falk E. Mechanisms of plaque formation and rupture. Circ Res. 2014;114(12):1852–66.CrossRefPubMed
28.
Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of myocardial infarction 2 participants. N Engl J Med. 1999;341(4):217–25.CrossRefPubMed
29.
Lansky AJ, Ng VG, Maehara A, Weisz G, Lerman A, Mintz GS, et al. Gender and the extent of coronary atherosclerosis, plaque composition, and clinical outcomes in acute coronary syndromes. JACC Cardiovasc Imaging. 2012;5(3 Suppl):S62–72.CrossRefPubMed
30.
Schulman-Marcus J, Hartaigh B, Gransar H, Lin F, Valenti V, Cho I, et al. Sex-specific associations between coronary artery plaque extent and risk of major adverse cardiovascular events: the CONFIRM long-term registry. JACC Cardiovasc Imaging. 2016;9(4):364–72.CrossRefPubMedPubMedCentral
31.
Sun Y, Qi G, Yu X, Zhi Y, Geng S, Li H, et al. Prevalence, severity, characteristics and coronary calcified score of coronary artery plaques are different in women than men with suspected coronary artery disease. Zhonghua Yi Xue Za Zhi. 2015;95(41):3337–42.PubMed
32.
• Plank F, Beyer C, Friedrich G, Wildauer M, Feuchtner G. Sex differences in coronary artery plaque composition detected by coronary computed tomography: quantitative and qualitative analysis. Neth Heart J. 2019;27(5):272–80. This was a comprehensive study comparing plaque composition and major cardiovascular events between sexes.CrossRefPubMedPubMedCentral
33.
Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on cardiovascular imaging and intervention, council on cardiovascular radiology and intervention, and committee on cardiac imaging, Council on Clinical Cardiology. Circulation. 2006;114(16):1761–91.
34.
35.
Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15(4):827–32.CrossRefPubMed
36.
Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122(25):e584–636.PubMed
37.
38.
•• Hecht HS, Cronin P, Blaha MJ, Budoff MJ, Kazerooni EA, Narula J, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr. 2017;11(1):74–84. SCCT guidelines for current CAC and risk model.CrossRefPubMed
39.
Rumberger JA, Simons DB, Fitzpatrick LA, Sheedy PF, Schwartz RS. Coronary artery calcium area by electron-beam computed tomography and coronary atherosclerotic plaque area. A histopathologic correlative study. Circulation. 1995;92(8):2157–62.CrossRefPubMed
40.
Simons DB, Schwartz RS, Edwards WD, Sheedy PF, Breen JF, Rumberger JA. Noninvasive definition of anatomic coronary artery disease by ultrafast computed tomographic scanning: a quantitative pathologic comparison study. J Am Coll Cardiol. 1992;20(5):1118–26.CrossRefPubMed
41.
Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffmann U, Hoffman U, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009;2(6):675–88.CrossRefPubMed
42.
Ceponiene I, Nakanishi R, Osawa K, Kanisawa M, Nezarat N, Rahmani S, et al. Coronary artery calcium progression is associated with coronary plaque volume progression: results from a quantitative semiautomated coronary artery plaque analysis. JACC Cardiovasc Imaging. 2018;11(12):1785–94.CrossRefPubMed
43.
Raggi P, Shaw LJ, Berman DS, Callister TQ. Gender-based differences in the prognostic value of coronary calcification. J Women’s Health (Larchmt). 2004;13(3):273–83.CrossRef
44.
Lessmann N, de Jong PA, Celeng C, Takx RAP, Viergever MA, van Ginneken B, et al. Sex differences in coronary artery and thoracic aorta calcification and their association with cardiovascular mortality in heavy smokers. JACC Cardiovasc Imaging. 2019;12(9):1808–17.CrossRefPubMed
45.
Mitchell TL, Pippin JJ, Devers SM, Kimball TE, Cannaday JJ, Gibbons LW, et al. Age- and sex-based nomograms from coronary artery calcium scores as determined by electron beam computed tomography. Am J Cardiol. 2001;87(4):453–6 A6.CrossRefPubMed
46.
Nasir K, Raggi P, Rumberger JA, Braunstein JB, Post WS, Budoff MJ, et al. Coronary artery calcium volume scores on electron beam tomography in 12,936 asymptomatic adults. Am J Cardiol. 2004;93(9):1146–9.CrossRefPubMed
47.
McClelland RL, Chung H, Detrano R, Post W, Kronmal RA. Distribution of coronary artery calcium by race, gender, and age: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2006;113(1):30–7.CrossRefPubMed
48.
Hoff JA, Chomka EV, Krainik AJ, Daviglus M, Rich S, Kondos GT. Age and gender distributions of coronary artery calcium detected by electron beam tomography in 35,246 adults. Am J Cardiol. 2001;87(12):1335–9.CrossRefPubMed
49.
Schmermund A, Möhlenkamp S, Stang A, Grönemeyer D, Seibel R, Hirche H, et al. Assessment of clinically silent atherosclerotic disease and established and novel risk factors for predicting myocardial infarction and cardiac death in healthy middle-aged subjects: rationale and design of the Heinz Nixdorf RECALL study. Risk factors, evaluation of coronary calcium and lifestyle. Am Heart J. 2002;144(2):212–8.CrossRefPubMed
50.
Erbel R, Delaney JA, Lehmann N, McClelland RL, Möhlenkamp S, Kronmal RA, et al. Signs of subclinical coronary atherosclerosis in relation to risk factor distribution in the Multi-Ethnic Study of Atherosclerosis (MESA) and the Heinz Nixdorf Recall Study (HNR). Eur Heart J. 2008;29(22):2782–91.CrossRefPubMedPubMedCentral
51.
Pereira AC, Gomez LM, Bittencourt MS, Staniak HL, Sharovsky R, Foppa M, et al. Age, gender, and race-based coronary artery calcium score percentiles in the Brazilian longitudinal study of adult health (ELSA-Brasil). Clin Cardiol. 2016;39(6):352–9.CrossRefPubMedPubMedCentral
52.
• Blaha MJ, Mortensen MB, Kianoush S, Tota-Maharaj R, Cainzos-Achirica M. Coronary artery calcium scoring: is it time for a change in methodology? JACC Cardiovasc Imaging. 2017;10(8):923–37. Paper outlining a proposed CAC model.CrossRefPubMed
53.
Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart Disease and Stroke Statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–e528.CrossRefPubMed
54.
Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, et al. Acute myocardial infarction in women: a scientific statement from the American Heart Association. Circulation. 2016;133(9):916–47.CrossRefPubMed
55.
Bellasi A, Raggi P, Merz CN, Shaw LJ. New insights into ischemic heart disease in women. Cleve Clin J Med. 2007;74(8):585–94.CrossRefPubMed
56.
Gupta A, Wang Y, Spertus JA, Geda M, Lorenze N, Nkonde-Price C, et al. Trends in acute myocardial infarction in young patients and differences by sex and race, 2001 to 2010. J Am Coll Cardiol. 2014;64(4):337–45.CrossRefPubMedPubMedCentral
57.
Bullock-Palmer RP, Shaw LJ, Gulati M. Emerging misunderstood presentations of cardiovascular disease in young women. Clin Cardiol. 2019;42(4):476–83.CrossRefPubMedPubMedCentral
58.
Bucholz EM, Strait KM, Dreyer RP, Lindau ST, D’Onofrio G, Geda M, et al. Editor’s choice-sex differences in young patients with acute myocardial infarction: a VIRGO study analysis. Eur Heart J Acute Cardiovasc Care. 2017;6(7):610–22.CrossRefPubMed
59.
Tamis-Holland JE, Jneid H. Myocardial infarction with nonobstructive coronary arteries (MINOCA): it’s time to face reality! J Am Heart Assoc. 2018;7(13).
60.
Michos ED, Nasir K, Braunstein JB, Rumberger JA, Budoff MJ, Post WS, et al. Framingham risk equation underestimates subclinical atherosclerosis risk in asymptomatic women. Atherosclerosis. 2006;184(1):201–6.CrossRefPubMed
61.
Lakoski SG, Greenland P, Wong ND, Schreiner PJ, Herrington DM, Kronmal RA, et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as "low risk" based on Framingham risk score: the multi-ethnic study of atherosclerosis (MESA). Arch Intern Med. 2007;167(22):2437–42.CrossRefPubMed
62.
Budoff MJ, Hokanson JE, Nasir K, Shaw LJ, Kinney GL, Chow D, et al. Progression of coronary artery calcium predicts all-cause mortality. JACC Cardiovasc Imaging. 2010;3(12):1229–36.CrossRefPubMed
63.
Kelkar AA, Schultz WM, Khosa F, Schulman-Marcus J, O’Hartaigh BW, Gransar H, et al. Long-term prognosis after coronary artery calcium scoring among low-intermediate risk women and men. Circ Cardiovasc Imaging. 2016;9(4):e003742.CrossRefPubMed
64.
65.
Kavousi M, Desai CS, Ayers C, Blumenthal RS, Budoff MJ, Mahabadi AA, et al. Prevalence and prognostic implications of coronary artery calcification in low-risk women: a meta-analysis. JAMA. 2016;316(20):2126–34.CrossRefPubMed
Metadata
Title
Sex Differences in Coronary Artery Calcium and Long-term CV Mortality
Authors
Allison Bigeh
Chandana Shekar
Martha Gulati
Publication date
01-04-2020
Publisher
Springer US
Published in
Current Cardiology Reports / Issue 4/2020
Print ISSN: 1523-3782
Electronic ISSN: 1534-3170
DOI
https://doi.org/10.1007/s11886-020-1267-9

Other articles of this Issue 4/2020

Current Cardiology Reports 4/2020 Go to the issue

Ischemic Heart Disease (D Mukherjee, Section Editor)

Current Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Intervention

Cardiac PET, CT, and MRI (P Schoenhagen and H Chen, Section Editors)

3D Printing Applications for Transcatheter Aortic Valve Replacement

Congenital Heart Disease (RA Krasuski, Section Editor)

What Every Cardiologist Should Know About the 2018 Updated Adult Congenital Cardiology Guidelines

Ischemic Heart Disease (D Mukherjee, Section Editor)

The Clinical Significance of Physiological Assessment of Residual Ischemia After Percutaneous Coronary Intervention

Ischemic Heart Disease (D Mukherjee, Section Editor)

Association Between Obesity and Cardiovascular Outcomes: Updated Evidence from Meta-analysis Studies

Ischemic Heart Disease (D Mukherjee, Section Editor)

Effects of Sleep Duration on Cardiovascular Events

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits