Sex-Related Differences in Calcific Aortic Stenosis

Study Questions:

Do sex-related differences exist for calcific aortic valve stenosis?


Consecutive patients undergoing aortic valve replacement at a large Midwest center between January 2010 and December 2012, were included in this analysis. Patients had either severe aortic stenosis (AS) or moderate AS with an additional indication for cardiac surgery. Patients were excluded if they had moderate or severe aortic regurgitation, a history of aortic valve endocarditis, prior balloon valvuloplasty, or hypertrophic obstructive cardiomyopathy. Clinical and echocardiographic characteristics were collected and correlated to excised aortic valve weight (AVW) in 888 patients, and for 126, AVW was correlated to computed tomography aortic valve calcium score.


Of the 888 patients, 63% were male and the mean age was 74 years. Women were slightly older and had smaller body surface area, and were less likely to have coronary artery disease and/or prior coronary artery bypass graft surgery compared to the men. Women and men had similar indexed valve area (0.42 ± 0.09 vs. 0.42 ± 0.07 cm2/m2, p = 0.95) and mean systolic gradient (53 ± 15 vs. 52 ± 13 mm Hg, p = 0.11). Women had higher New York Heart Association class symptoms (2.63 ± 0.70 vs. 2.50 ± 0.70, p = 0.0), and less prevalent coronary artery disease (38 vs. 52%, p < 0.0001). AVW was lower in women (1.94 ± 0.88 vs. 3.08 ± 1.32 g, p < 0.0001) even when indexed to body surface area (1.09 ± 0.48 vs. 1.48 ± 0.62 g/m2, p < 0.0001) or left ventricular outflow tract (LVOT) area (0.54 ± 0.23 vs. 0.71 ± 0.29 g/cm2, p < 0.0001). Using multivariate analysis, male sex (p < 0.0001), bicuspid valve (p < 0.0001), and larger LVOT area (p < 0.0001) were the major determinants of increased AVW, along with current cigarette smoking (p = 0.007). Diabetes (p = 0.004) and hypertension (p = 0.03) were independently associated with lower AVW. Aortic valve calcium correlated well with AVW (r = 0.81, p < 0.0001) and was lower in women than in men (2520 ± 1199 vs. 3606 ± 1632 arbitrary units, p < 0.0001).


The investigators concluded that women had similar degrees of AS to men, but with less aortic valve calcium and lower AVW compared to men. Aortic valve calcium was correlated to excised AVW and valve weight was associated with hypertension, current smoking, and diabetes.


These data suggest clinically relevant differences in the development of aortic valve disease between men and women. Understanding the mechanisms between gender differences will likely improve management of aortic valve disease in the future.

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