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Published on: September 22, 2023
Gender Differences in the Atherosclerosis Profile by Coronary CTA in Coronary Artery Calcium Score Zero Patients
Thomas Senoner1, Fabian Plank1, Christoph Beyer2
1Department of Internal Medicine III-Cardiology and Angiology, Innsbruck Medical University, 6020 Innsbruck, Austria.
Insights
Men with zero coronary artery calcium score (CACS) show more atherosclerosis, but women experience higher long-term mortality and symptoms. This highlights sex-based differences in cardiovascular risk despite similar initial CACS findings.
Area of Science:
- Cardiovascular Imaging and Diagnostics
- Cardiovascular Disease Epidemiology
- Sex Differences in Medicine
Background:
- Coronary artery calcium score (CACS) is vital for cardiovascular risk stratification.
- Coronary computed tomography angiography (CTA) offers detailed atherosclerosis analysis.
- Understanding gender disparities in atherosclerosis is crucial for risk assessment.
Purpose of the Study:
- To investigate sex-based differences in atherosclerosis profiles using CTA among patients with a CACS of zero.
- To compare plaque characteristics and clinical outcomes between males and females with minimal or no coronary calcification.
Main Methods:
- 1451 low- to intermediate-risk patients with CACS <1.0 Agatston units (AU) underwent CTA and CACS.
- Propensity score matching created a 1:1 male-to-female ratio for analysis.
- CTA evaluated stenosis severity, plaque burden (G-score), and high-risk plaque (HRP) criteria; outcomes included mortality and major adverse cardiovascular events (MACEs).
Main Results:
- Males with CACS of 0 showed higher prevalence of atherosclerosis (32.1% vs. 20.3%), nonobstructive CAD, greater plaque burden, and more HRP criteria compared to females.
- No significant difference in atherosclerosis was observed between sexes with ultralow CACS (0.1-0.9 AU).
- Females experienced higher all-cause mortality (3.5% vs. 1.8%) and were more frequently symptomatic with chest pain (70% vs. 61.6%) over a mean 6.6-year follow-up.
Conclusions:
- In patients with a CACS of 0, males exhibit a greater burden of noncalcified atherosclerosis and high-risk plaque features.
- Despite less apparent atherosclerosis on CTA, females face poorer long-term outcomes and increased symptom burden.
- These findings underscore the importance of considering sex-specific factors in cardiovascular risk assessment, even with minimal coronary calcification.
Abstract:
Background: The coronary artery calcium score (CACS) is a powerful tool for cardiovascular risk stratification. Coronary computed tomography angiography (CTA) allows for a more distinct analysis of atherosclerosis. The aim of the study was to assess gender differences in the atherosclerosis profile of CTA in patients with a CACS of zero. Methods: A total of 1451 low- to intermediate-risk patients (53 ± 11 years; 51% females) with CACS <1.0 Agatston units (AU) who underwent CTA and CACS were included. Males and females were 1:1 propensity score-matched. CTA was evaluated for stenosis severity (Coronary Artery Disease - Reporting and Data System (CAD-RADS) 0-5: minimal <25%, mild 25-49%, moderate 50-69%, severe ≥70%), mixed-plaque burden (G-score), and high-risk plaque (HRP) criteria (low-attenuation plaque, spotty calcification, napkin-ring sign, and positive remodeling). All-cause mortality, cardiovascular mortality, and major cardiovascular events (MACEs) were collected. Results: Among the patients, 88.8% had a CACS of 0 and 11.2% had an ultralow CACS of 0.1-0.9 AU. More males than females (32.1% vs. 20.3%; p < 0.001) with a CACS of 0 had atherosclerosis, while, among those with an ultralow CACS, there was no difference (88% vs. 87.1%). Nonobstructive CAD (25.9% vs. 16.2%; p < 0.001), total plaque burden (2.2 vs. 1.4; p < 0.001), and HRP were found more often in males (p < 0.001). After a follow-up of mean 6.6 ± 4.2 years, all-cause mortality was higher in females (3.5% vs. 1.8%, p = 0.023). Cardiovascular mortality and MACEs were low (0.2% vs. 0%; p = 0.947 and 0.3% vs. 0.6%; p = 0.790) for males vs. females, respectively. Females were more often symptomatic for chest pain (70% vs. 61.6%; p = 0.004). (4) Conclusions: In patients with a CACS of 0, males had a higher prevalence of atherosclerosis, a higher noncalcified plaque burden, and more HRP criteria. Nonetheless, females had a worse long-term outcome and were more frequently symptomatic.
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