Coronary calcium: ‘bad news’ for men, but even ‘worse news’ for women?

This editorial refers to ‘Sex differences in calcified plaque and long-term cardiovascular mortality: observations from the CAC Consortium’†, by Shaw et al., on page 3727. Cardiovascular disease differs between men and women not only regarding its incidence and prevalence, but also regarding the type of clinical manifestation.1 , 2 For example, stroke and heart failure are more frequently the initial presentation of cardiovascular disease in women than in men, while myocardial infarction is a more frequent first manifestation of cardiovascular disease in men than in women.3 At the same time, survival for many types of heart disease is worse in women than in men, including atrial fibrillation,4 hypertrophic cardiomyopathy,5 and myocardial infarction.6 In acute coronary syndromes, female patients more frequently present with atypical symptoms, and women suffer from a longer delay between symptom onset and treatment.7–10 Furthermore, women seem to have a different distribution of mechanisms leading to intracoronary thrombus formation than men, especially when young.11–13 These findings nurture the notion that atherosclerotic plaque composition and mechanisms underlying acute coronary events in women may be substantially different from that in men (a hypothesis that is not unanimously supported by data).14 , 15 However, as a consequence, this would lead to the conclusion that if cardiovascular risk factors or imaging findings are used for refined targeting of preventive therapies, risk assessment algorithms, target variables, and treatment thresholds likely need to be different between male and female individuals.