Postmenopausal women at higher risk of heart attacks than men of similar age, study finds

New research presented at the EACVI 2023 scientific congress by the European Society of Cardiology (ESC) and published in the European Heart Journal—Cardiovascular Imaging indicates that postmenopausal women with clogged arteries face a higher risk of heart attacks than men of a similar age. The study, which tracked nearly 25,000 adults using imaging techniques to examine their arteries, followed patients for heart attacks and death.

According to Dr. Sophie van Rosendael of Leiden University Medical Centre in the Netherlands, who served as the study’s lead author, “The study suggests that a given burden of atherosclerosis is riskier in postmenopausal women than it is in men of that age. Since atherosclerotic plaque burden is emerging as a target to decide the intensity of therapy to prevent heart attacks, the findings may impact treatment. Our results indicate that after menopause, women may need a higher dose of statins or the addition of another lipid-lowering drug. More studies are needed to confirm these findings.”

Atherosclerosis occurs when fat and cholesterol deposits accumulate, narrowing the arteries. Women generally develop atherosclerosis later in life than men and have heart attacks at an older age than men due in part to the protective effects of estrogen, although young women can experience heart attacks as well. This study aimed to determine if the prognostic importance of atherosclerotic plaques is the same for women and men of different ages, which could have significant implications for selecting treatments to prevent heart attacks.

The study enrolled 24,950 patients who were referred for coronary computed tomography angiography (CCTA) and were part of the CONFIRM registry conducted in North America, Europe, and Asia. CCTA is a medical imaging technique used to produce 3D images of the heart’s arteries.

Researchers used the Leiden CCTA score to assess the total atherosclerotic burden of each patient. The score takes into account plaque presence, composition, location, and severity of narrowing for each coronary segment, producing a final value of 0 to 42. Patients were divided into three categories based on their atherosclerotic burden: low, medium, and high. Obstructive coronary artery disease was defined as 50% narrowing or more.

The study’s primary objective was to compare the Leiden CCTA scores of women and men of a similar age. The researchers also analyzed sex differences in major adverse cardiovascular events (MACE), which included all-cause death and myocardial infarction, after adjusting for age and cardiovascular risk factors such as hypertension, high cholesterol, diabetes, current smoking, and family history of coronary artery disease.

Over 11,000 women (average age 58.5 years) and 13,000 men (average age 55.6 years) were followed for an average of 3.7 years. The study revealed that women experience a 12-year delay in the onset of coronary atherosclerosis compared to men, with the median Leiden CCTA risk score above zero at age 64 to 68 years for women and 52 to 56 years for men (p<0.001). Additionally, the overall plaque burden was significantly lower in women, who had more non-obstructive disease.

Dr. van Rosendael commented, “Our findings confirm that women experience a delay in the onset of atherosclerosis and are more likely to have non-obstructive disease. While it was previously believed that only obstructive atherosclerosis caused myocardial infarction, we now know that non-obstructive disease also poses a risk.”

For premenopausal women and men under 55 years old, the burden of atherosclerosis was similarly predictive of MACE. However, for postmenopausal women aged 55 years and older, the risk of MACE was higher than in men with a similar score. In postmenopausal women, those with medium and high burdens had 2.21-fold and 6.11-fold higher risks of MACE compared to those with low burdens. Whereas, in men over 55 years old, those with medium and high burdens had 1.57-fold and 2.25-fold greater risks of MACE compared to those with low burdens.

According to Dr. van Rosendael, the study showed that the risk of MACE was particularly elevated in postmenopausal women with the highest Leiden CCTA score. This might be partly due to the fact that coronary arteries are narrower in women, causing the same amount of plaque to have a greater impact on blood flow. The study suggests that there is a significant increase in the relative risk for postmenopausal women compared to men, even with a similar burden of atherosclerotic disease. These findings may have implications for the intensity of medical treatment.

Source: European Society of Cardiology

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