Sex Differences in Atherosclerosis and its Clinical Complications

This review examines sex- and gender- specific differences in the pathophysiology, presentation, and clinical complications of atherosclerosis. We explore both traditional and emerging risk factors and identify diagnostic and treatment gaps that disproportionately affect women.

Traditional risk factors such as diabetes and smoking confer greater cardiovascular risk in women than men. Women also experience unique risk factors, including adverse pregnancy outcomes, polycystic ovary syndrome, early menopause, and higher prevalence of autoimmune diseases, that further elevate their risk. Women are more likely to experience ischemia and myocardial infarction in the setting of non-obstructive coronary disease (INOCA/MINOCA). Despite having less plaque than men at any given age, high risk features on cardiac computed tomography angiography carry greater risk. Women are also less likely to receive lipid-lowering agents and other preventive therapies. Recognizing sex-based differences in atherosclerosis is critical to advancing more nuanced, equitable, and personalized cardiovascular disease prevention and care.