Sex Differences in Coronary Arterial Calcification in Symptomatic Patients

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Despite the increasing use of Coronary Artery Calcium (CAC) scoring for cardiovascular risk stratification in asymptomatic patients, the gender differences in CAC among symptomatic patients have not been well evaluated. We analyzed patients presenting to the emergency department (ED) with chest pain suggesting possible coronary artery disease (CAD) who received coronary computed tomography angiography (CCTA). Ordinal logistic regression was used to determine the odds ratio for the association of traditional cardiovascular risk factors and CAC. Patients with a CAC score ≥ 100 were followed for cardiovascular events or changes in medical management. Our cohort included 542 individuals (263 male, 279 female). Ordinal logistic regression model showed that among traditional cardiovascular risk factors, male sex had the highest odds ratio (OR) of 3.04 (p < 0.001, 95% CI [2.01, 4.59]) for the presence of CAC. Also, males had more diffuse distribution of coronary atherosclerosis (p=0.01). Subgroup analysis revealed that obesity was a bigger risk factor in male patients (OR 2.16), while smoking showed the greatest effect (OR 4.27) on CAC in women. Of patients who had CAC > 100 with an average follow-up of 346 days, there was an increase in both aspirin and statin use, yet significant sex differences were observed especially in patients with non-obstructive lesions on CCTA. Among male patients with non-obstructive lesions, 68.2% were on aspirin and 86.4% were on statin therapy after the CCTA compared to 27.3% and 45.5% respectively in their female counterparts. In conclusion, sex not only is the most powerful predictor for higher CAC among traditional cardiovascular risk factors in symptomatic patients but also influences the contribution of various traditional risk factors to elevated CAC. Furthermore, the discovery of CAD led to the initiation of medical therapy in male patients more frequently than in female patients, even after adjusting for the degree of luminal stenosis detected on coronary CT angiography.

Section snippets

Methods

This retrospective cohort study was approved by the IRB of Northwell Health. Our study included all patients ≥ 18 years of age, who presented to the ED of North Shore University Hospital between January 2016 and December 2017 with chest pain suggesting possible coronary artery disease (CAD) and who received coronary computed tomography angiography (CCTA) which included a CAC score. Race was categorized as Caucasian, Black, Asian, and other. Hypertension and hyperlipidemia were considered to be

Results

From January 2016 to December 2017, a total of 542 patients had CCTA done with a CAC score quantified. Baseline demographic and clinical characteristics are shown in Table 1. There were 263 men (48.5%) and 279 women (51.5%) in the study population. Women were generally older (p = 0.026) and had a higher percentage of mild decrease in creatinine clearance (p=0.02) while men were more often smokers (p < 0.001) and more likely to have hyperlipidemia (p=0.013). A higher percentage of women were

Discussion

Acute coronary syndrome is usually a consequence of thromboembolic events due to atherosclerosis and plaque rupture. Sex difference in CAD development is multifactorial and includes hormonal differences, differences in vascular beds, and atherosclerotic characteristics. Despite increasing interest in sex-specific evidence to improve outcomes, our understanding of sex differences in atherosclerosis remains suboptimal.10 In this study, we report on sex-specific risk factor analysis and vessel

Conclusion

Our study demonstrates that sex is the most powerful predictor for higher CAC score among traditional cardiovascular risk factors in symptomatic patients, and men also tend to have more diffuse CAD compared to women. In addition, we showed that there is a sex difference in the contribution of various traditional risk factors to elevated CAC score, as obesity was the most powerful predictor in men, while smoking and diabetes had higher impact on CAC score in women.

Conflict of Interest

Conflict of Interest for all authors: None

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (27)

  • U Hoffmann et al.

    Defining normal distributions of coronary artery calcium in women and men (from the Framingham Heart Study)

    Am J Cardiol

    (2008)
  • LJ Shaw et al.

    Sex differences in calcified plaque and long-term cardiovascular mortality: observations from the CAC Consortium

    Eur Heart J

    (2018)
  • RL McClelland et al.

    Distribution of coronary artery calcium by race, gender, and age: results from the multi-ethnic study of atherosclerosis (MESA)

    Circulation

    (2006)
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    Author Contribution: Beom Soo Kim: Conceptualization, Methodology, Investigation, Data Curation, Formal analysis, Writing – Original draft preparation, Visualization Nicholas Chan: Investigation Greg Hsu: investigation Amgad N. Makaryus: Review & Editing, Maya Chopra: Investigation Stuart Cohen: Data Curation, Writing – Review & Editing, Supervision John N. Makaryus: Data Curation, Writing – Review & Editing, Supervision

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