News Release

Women with hardened arteries may need stronger treatment to prevent heart attacks than men

Reports and Proceedings

European Society of Cardiology

Barcelona, Spain – 11 May 2023:  Postmenopausal women with clogged arteries are at higher risk of heart attacks than men of similar age, according to research presented at EACVI 2023, a scientific congress of the European Society of Cardiology (ESC),1 and published in European Heart Journal - Cardiovascular Imaging.2 The study in nearly 25,000 adults used imaging techniques to examine the arteries and followed patients for heart attacks and death.

“The study suggests that a given burden of atherosclerosis is riskier in postmenopausal women than it is in men of that age,” said study author Dr. Sophie van Rosendael of Leiden University Medical Centre, the Netherlands. “Since atherosclerotic plaque burden is emerging as a target to decide the intensity of therapy to prevent heart attacks, the findings may impact treatment. Our results indicate that after menopause, women may need a higher dose of statins or the addition of another lipid-lowering drug. More studies are needed to confirm these findings.”

Atherosclerosis is the narrowing of arteries due to deposits of fat and cholesterol in what is called plaque. While young women do have heart attacks, in general, women develop atherosclerosis later in life than men and have heart attacks at an older age than men,3 in part because of the protective effect of oestrogen. This study examined whether the prognostic importance of atherosclerotic plaques are the same for women and men at different ages as this could be important for selecting treatments to prevent heart attacks.

The study included 24,950 patients referred for coronary computed tomography angiography (CCTA) and enrolled in the CONFIRM registry, which was conducted in six countries in North America, Europe, and Asia. CCTA is used to obtain 3D images of the arteries in the heart.

Total atherosclerotic burden was rated using the Leiden CCTA score, which incorporates the following items for each coronary segment: plaque presence (yes/no), composition (calcified, noncalcified or mixed), location, and severity of narrowing, for a final value of 0 to 42.4 Patients were divided into three categories previously found to predict the risk myocardial infarction: low atherosclerotic burden (0 to 5), medium (6 to 20) and high (over 20). In addition, obstructive coronary artery disease was defined as 50% narrowing or more.

The primary outcome was the difference in Leiden CCTA score between women and men of similar age. The investigators also analysed sex differences in the rates of major adverse cardiovascular events (MACE), which included all-cause death and myocardial infarction, after adjusting for age and cardiovascular risk factors (hypertension, high cholesterol, diabetes, current smoking and family history of coronary artery disease).

A total of 11,678 women (average age 58.5 years) and 13,272 men (average age 55.6 years) were followed for 3.7 years. Regarding the primary outcome, the study showed an approximately 12 year delay in the onset of coronary atherosclerosis in women: the median Leiden CCTA risk score was above zero at age 64 to 68 years in women versus 52 to 56 years in men (p<0.001). In addition, the overall plaque burden as quantified by the Leiden CCTA score was significantly lower in women, who had more non-obstructive disease.

Dr. van Rosendael said: “The results confirm the previously reported delay in the start of atherosclerosis in women. We also found that women are more likely to have non-obstructive disease. It was formerly thought that only obstructive atherosclerosis caused myocardial infarction but we now know that non-obstructive disease is also risky.”

The burden of atherosclerosis was equally predictive of MACE in premenopausal women (aged under 55 years) and men of the same age group. However, in postmenopausal women (age 55 years and older), the risk of MACE was higher than men for a given score. In postmenopausal women, compared to those with a low burden, those with a medium and high burden had 2.21-fold and 6.11-fold higher risks of MACE. While in men aged 55 years and older, compared to those with a low burden, those with a medium and high burden had 1.57-fold and 2.25-fold greater risks of MACE.

Dr. van Rosendael said: “In this study, the elevated risk for women versus men was especially observed in postmenopausal women with the highest Leiden CCTA score. This could be partly because the inner diameter of coronary arteries is smaller in women, meaning that the same amount of plaque could have a larger impact on blood flow. Our findings link the known acceleration of atherosclerosis development after menopause with a significant increase in relative risk for women compared to men, despite a similar burden of atherosclerotic disease. This may have implications for the intensity of medical treatment.”



Authors: ESC Press Office
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Notes to editor

Funding: None.

Disclosures: Dr. Lin has received grants from GE Healthcare outside the submitted work. Dr. Budoff has received grants from General Electric outside the submitted work. Dr. Chinnaiyan is a non-compensated medical advisory board member of Heartflow Inc. Dr. Benjamin Chow holds the Saul and Edna Goldfarb Chair in Cardiac Imaging Research. He receives research support from TD Bank, Siemens Healthineers, and Artrya. He is a consultant for and has equity interest in Artrya. Dr. Jonathon Leipsic is a consultant to and holds stock options in Circle CVI and HeartFlow and has received modest speaking fees from Philips and GE Healthcare. Dr. James K. Min is an employee of Cleerly Inc. Dr. Shaw reported receiving honorarium for scientific presentations from Heartflow and serving on the scientific advisory boards for Elucid and Covanos Inc. The remaining authors have no relevant disclosures.


References and notes

1The abstract ‘Sex and age-specific interactions of coronary atherosclerotic plaque onset and prognosis from coronary CT’ will be presented during the session ‘Computerised tomography angiography in the heart of cardiovascular imaging’ which takes place on 11 May at 11:30 CEST in Teatro Científico.

2van Rosendael SE, Bax AM, Lin FY, et al. Sex and age-specific interactions of coronary atherosclerotic plaque onset and prognosis from coronary CT. Eur Heart J Cardiovasc Imaging. 2023. doi:10.1093/ehjci/jead094.

Link will go live on publication:

3Hochman JS, Tamis JE, Thompson TD, 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;341:226–232.

4van Rosendael AR, Shaw LJ, Xie JX, et al. Superior risk stratification with coronary computed tomography angiography using a comprehensive atherosclerotic risk score. JACC Cardiovasc Imaging. 2019;12:1987–1997.


About EACVI 2023    #EACVI2023

EACVI 2023 is the first patient-focused and unified multi-modality congress. It is organised by the European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology (ESC).


About the European Association of Cardiovascular Imaging (EACVI)

The European Association of Cardiovascular Imaging (EACVI) - a branch of the ESC - is the world leading network of Cardiovascular Imaging (CVI) experts, gathering four imaging modalities under one entity (Echocardiography, Cardiovascular Magnetic Resonance, Nuclear Cardiology and Cardiac Computed Tomography). Its aim is to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging. The EACVI welcomes over 11,000 professionals including cardiologists, sonographers, nurses, basic scientists and allied professionals.


About the European Society of Cardiology

The European Society of Cardiology brings together health care professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.


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