• Prevention & Screening
• Coronary Artery Disease

• Cardiology & Cardiovascular Medicine
• Prevention & Screening
• Coronary Artery Disease

Pamela Ouyang, MBBS, Johns Hopkins University, Baltimore, Maryland, USA, discussed sex differences in risk factors for the development and assessment of coronary artery disease (CAD). Cardiovascular disease (CVD) risk factors are similar for men and women; however, the prevalence of these risk factors differs between the sexes. Hypertension is more common in women aged > 65 years. Physical inactivity rates are higher and smoking rates are lower in women. Diabetes is more prevalent and may impart a higher CVD risk in women [Kalyani RR et al. Diabetes Care 2013].

The American College of Cardiology (ACC) National Cardiovascular Data Registry reported that significant obstructive CAD is less common in women than in men (p < .0001) [Shaw L et al. Circulation 2008]. Among white women and men with angina and CAD, women had a higher in-hospital mortality rate but lower rates of treatment with coronary revascularization and aspirin.

A Finnish study showed that the presence of angina and coronary artery diagnosed by either stress test or angiography was associated with higher mortality rates in women than in men aged 45 to 74 years [Hemingway H et al. JAMA 2006]. In a sample of 136,247 patients (28% women) from 11 acute coronary syndrome (ACS) trials, 30-day mortality rates were significantly higher among women with ST-segment elevation myocardial infarction (STEMI; adjusted OR, 1.15; 95% CI, 1.06 to 1.24; p <.005) and lower among women with unstable angina (adjusted OR, .55; 95% CI, .43 to .70; p < .005) compared with men with the same diagnoses [Berger JS et al. JAMA 2009].

Women with chest pain have a lower rate of anatomic coronary disease but are hospitalized more often for persistent chest pain [Shaw L et al. J Am Coll Cardiol 2009]. Women with atypical chest pain or chest pain with no obstructive CAD have an increased risk of adverse events [Gulati M et al. Arch Intern Med 2009; Robinson JG et al. Am J Cardiol 2008]. Women with sudden cardiac arrest have significantly lower CAD rates and less severe left ventricular dysfunction than men [Chugh SS et al. J Am Coll Cardiol 2009].

The Framingham Risk Score (FRS) and American Heart Association/ACC Cardiovascular Risk Guidelines Work Group pooled cohort risk equations are used to assess atherosclerotic CVD (ASCVD) risk [Goff et al. Circulation 2013]. Women, however, can be misclassified if these scores are used alone. Nontraditional factors that increase cardiovascular risk include a family history of premature CVD; high-sensitivity C-reactive protein ≥ 2 mg/L; coronary artery calcification (CAC) score ≥ 300 Agatston units or ≥ 75th percentile for age, sex, and ethnicity; and ankle-brachial index < .9. Additional risk factors in women include menarche age, menopause age, and gestational diabetes or hypertensive disorders during pregnancy.

Another recent study showed that a patient's predicted risk of cardiovascular events as assessed by the FRS could be modified with the CAC scoring [Erbel et al. J Am Coll Cardiol 2010]. As a result, it possible to use CAC scores to reclassify intermediate-risk patients into either a higher (or lower) risk category.

Women with chest pain have a less severe extent of coronary obstruction than do men. Nonobstructive coronary disease is, however, associated with increased risk versus normal coronary arteries. Causes of chest pain other than ASCVD are more common in women. Risk stratification tools may misclassify some intermediate-risk women. Therefore, Dr. Ouyang concluded that additional testing should be considered in women with high levels of a single risk factor.

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