Sex Differences in Calcified Plaque and Long-Term CV Mortality

Study Questions:

What is the long-term cardiovascular disease (CVD) risk among women when compared with men based on measures of coronary artery calcium (CAC)?


Study data were from the CAC Consortium, a four-center cohort, which enrolled consecutive patients undergoing CAC scans between 1991 and 2010. All participants were asymptomatic and were referred by a physician for CAC scans to refine CVD risk screening. Pooled cohort equation 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). The primary outcome of interest was CV mortality.


A total of 63,215 patients were followed for a median of 12.6 years, of which 20,508 were women (mean age, 56.2 years) and 42,707 were men (mean age, 53.5 years). During follow-up, 919 CV-related deaths occurred. Women were more likely to be older, hypertensive, and have a family history of coronary heart disease, while men were more likely to report smoking and be obese. 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 a 1.3-higher hazard for CV death among women when compared with men (p < 0.001). CV mortality was higher among women with more extensive, numerous, or larger CAC lesions. The relative hazard for 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. 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.


The authors concluded 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.


These data suggest that plaque characteristics including size and extent of lesions may provide additive predictive value to CAC scoring, for women in particular.

Clinical Topics: Noninvasive Imaging, Prevention, Hypertension, Smoking

Keywords: Cardiovascular Diseases, Coronary Disease, Diagnostic Imaging, Hypertension, Obesity, Plaque, Atherosclerotic, Primary Prevention, Risk Factors, Sex Characteristics, Smoking

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