Key result
Detectable CAC linked to ~30% higher CV death risk in women versus men.
Why the study?
Current evidence on long-term cardiovascular risk among women compared with men based on coronary artery calcium measures remains incomplete.
Do sex differences in coronary artery calcium measures predict long-term cardiovascular mortality in asymptomatic individuals?
Cohort (n=63,215)
Yes
Do sex differences in coronary artery calcium measures predict long-term cardiovascular mortality in asymptomatic individuals?
Effect estimate: HR 1.3
p-value: p=<0.001
In asymptomatic individuals, detectable and extensive coronary artery calcium confers a disproportionately higher relative hazard for cardiovascular mortality in women compared to men.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our findings, showing significant levels of coronary calcium to predict mortality from cardiovascular causes more strongly in women than men with diabetes, might also help to explain the poorer prognosis for cardiovascular disease that has been observed for decades in women compared to men with diabetes”
“CVD remains the leading cause of death in women, yet women are often perceived as being at lower risk because they tend to have less coronary plaque overall. We were motivated to better understand whether amount of plaque carries the same prognostic meaning in women and men.”
CAC may identify higher CV death risk in women than men; leaves open sex-specific thresholds for risk stratification.
Aims: Pathologic evidence supports unique sex-specific mechanisms as precursors for acute cardiovascular (CV) events. Current evidence on long-term CV risk among women when compared with men based on measures of coronary artery calcium (CAC) remains incomplete. Methods and results: A total of 63 215 asymptomatic women and men were enrolled in the multicentre, CAC Consortium with median follow-up of 12.6 years. Pooled cohort equation (PCE) risk scores and risk factor data were collected with the Agatston score and other CAC measures (number of lesions and vessels, lesion size, volume, and plaque density). Cox proportional hazard models were employed to estimate CV mortality (n = 919). Sex interactions were calculated. Women and men had average PCE risk scores of 5.8% and 9.1% (P < 0.001). Within CAC subgroups, women had fewer calcified lesions (P < 0.0001) and vessels (P = 0.017), greater lesion size (P < 0.0001), and higher plaque density (P = 0.013) when compared with men. For women and men without CAC, long-term CV mortality was similar (P = 0.67), whereas detectable CAC was associated with 1.3-higher hazard for CV death among women when compared with men (P < 0001). Cardiovascular mortality was higher among women with more extensive, numerous, or larger CAC lesions. The relative hazard for cardiovascular disease (CVD) mortality for women and men was 8.2 vs. 5.1 for multivessel CAC, 8.6 vs. 5.9 for ≥5 CAC lesions, and 8.5 vs. 4.4 for a lesion size ≥15 mm3, respectively. Additional explorations revealed that women with larger sized and more numerous CAC lesions had 2.2-fold higher CVD mortality (P < 0.0001) as compared to men. Moreover, CAC density was not predictive of CV mortality in women (P = 0.51) but was for men (P < 0.001), when controlling for CAC volume and cardiac risk factors. Conclusion: Our overall findings support that measures beyond the Agatston score provide important clues to sex differences in atherosclerotic plaque and may further refine risk detection and focus preventive strategies of care.
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Shaw et al. (2018) conducted a cohort in Asymptomatic individuals (n=63,215). Detectable coronary artery calcium (CAC) vs. Men was evaluated on Cardiovascular mortality (HR 1.3, p=<0.001). Detectable coronary artery calcium was associated with a 1.3-fold higher hazard for cardiovascular death among women compared with men (P<0.001).
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