Sex differences in coronary artery plaque composition detected by coronary computed tomography: quantitative and qualitative analysis

Abstract

Background Sex differences in the calculation of coronary heart disease risk have been analysed extensively. However, data on coronary plaque morphology diverge. We analysed plaque characteristics in patients with suspected coronary artery disease (CAD) and defined prognostic factors using coronary computed tomography angiography (CCTA). Methods A total of 6,050 consecutive patients underwent CCTA and were enrolled in the registry. Patients with known CAD were excluded. The patients were propensity score matched (1:1 male:female) for age and known coronary risk factors. Coronary arteries were evaluated for stenosis, plaque types (non-calcified, mixed and calcified) and high-risk plaque features (napkin-ring sign, low-attenuation plaque, spotty calcifications, positive remodelling). Clinical follow-up was performed. Results A total of 1,050 patients (525 female, 525 male) in matched cohorts were selected for analysis. CCTA showed significantly higher calcium scores for males (mean 180.5 vs 67.8 AU, p < 0.0001) and a higher rate of CAD (66.0% vs 34.1%, p < 0.0001). In a total of 16,800 segments, males had significantly more plaques (861 vs 752, p < 0.0001) with a significantly larger proportion of calcified plaques, while females had more mixed and non-calcified plaques (33.5% vs 24.4%, p = 0.006 and 24.1% vs 13.6%, p = 0.22, respectively). After a mean follow-up of 5.6 years, major adverse cardiac event (MACE) rate was 5.3% in male and 1.9% in female patients ( p < 0.05). The relative odds ratio for high-risk plaque features to predict MACE was higher in females. Conclusion Based on a higher relative risk for women with high-risk plaque features, the findings of our study support the increased importance of a differentiated qualitative plaque analysis to improve the risk stratification for both sexes.

Gender Differences in the Atherosclerosis Profile by Coronary CTA in Coronary Artery Calcium Score Zero Patients

“…The higher total plaque burden in males compared with females in our study, known from cohorts with mild to severe calcium load (CACS >1.0 AU) [ 30 , 31 ], holds true also for patients with CACS 0.…”

“…Previous studies enrolling patients with positive CACS above >1.0 AU reported contradictory results [ 30 , 31 ]. Plank et al [ 30 ] analyzed 1050 patients (1:1 propensity score-matched) and found more calcified plaques in males, while females had more mixed and noncalcified plaques.…”

“…Previous studies enrolling patients with positive CACS above >1.0 AU reported contradictory results [ 30 , 31 ]. Plank et al [ 30 ] analyzed 1050 patients (1:1 propensity score-matched) and found more calcified plaques in males, while females had more mixed and noncalcified plaques. Another study observed a higher plaque burden in males compared to females, similar to our results [ 31 ], with males having a 6–7-fold higher odds ratio for increased burden of calcified and mixed calcified plaques, whereas no sex difference was observed for noncalcified plaques.…”

Sex differences in the manifestation and evolution of coronary artery plaques

“…This is especially true for sex-specific differences in the development, manifestation, and prognosis of coronary artery plaques. While the prevalence of obstructive CAD is higher in men compared to women, non-obstructive CAD and ischemia with no obstructive coronary arteries (INOCA) are relatively more common in women [1][2][3]. Compared to obstructive CAD, fewer established preventive, diagnostic and treatment options are available for INOCA [4], complicating treatment of CAD, especially in younger women at low cardiovascular risk.…”

“…Due to the heterogeneity between studies in terms of imaging modalities (invasive optical coherence tomography (OCT) [17,18] versus invasive intravascular ultrasound (IVUS) [19][20][21] versus noninvasive imaging (i.e. coronary computed tomography angiography; CCTA) [1,[22][23][24]) and investigated lesions (non-obstructive or obstructive [1,18,23,24] versus culprit lesions in myocardial infarction [17,19]) results concerning sex-differences were incoherent. In patients undergoing CCTA, the following findings were consistent between most studies: Men have higher plaque burden in terms of number of plaques and plaque volume, obstructive disease is more common in men, and the relative number of non-calcified plaque is higher in women than in men [1,[22][23][24].…”