Gender differences in coronary plaque composition and burden detected in symptomatic patients referred for coronary computed tomographic angiography

Discordance Between Coronary Artery Calcium Area and Density Predicts Long-Term Atherosclerotic Cardiovascular Disease Risk

BACKGROUND

Coronary artery calcium (CAC) is commonly quantified as the product of 2 generally correlated measures: plaque area and calcium density.

OBJECTIVES

The authors sought to determine whether discordance between calcium area and density has long-term prognostic importance in atherosclerotic cardiovascular disease (ASCVD) risk.

METHODS

The authors studied 10,373 primary prevention participants from the CAC Consortium with CAC >0. Based on their median values, calcium area and mean calcium density were divided into 4 mutually exclusive concordant/discordant groups. Cox proportional hazards regression assessed the association of calcium area/density groups with ASCVD mortality over a median of 11.7 years, adjusting for traditional risk factors and the Agatston CAC score.

RESULTS

The mean age was 56.7 years, and 24% were female. The prevalence of plaque discordance was 19% (9% low calcium area/high calcium density, 10% high calcium area/low calcium density). Female sex (odds ratio [OR]: 1.48 [95% CI: 1.27-1.74]) and body mass index (OR: 0.81 [95% CI: 0.76-0.87], per 5 kg/m2 higher) were significantly associated with high calcium density discordance, whereas diabetes (OR: 2.23 [95% CI: 1.85-3.19]) was most strongly associated with discordantly low calcium density. Compared to those with low calcium area/low calcium density, individuals with low calcium area/high calcium density had a 71% lower risk of ASCVD death (HR: 0.29 [95% CI: 0.09-0.95]).

CONCLUSIONS

For a given CAC score, high calcium density relative to plaque area confers lower long-term ASCVD risk, likely serving as an imaging marker of biological resilience for lesion vulnerability. Additional research is needed to define a robust definition of calcium area/density discordance for routine clinical risk prediction.

Evolving Role of Calcium Density in Coronary Artery Calcium Scoring and Atherosclerotic Cardiovascular Disease Risk

Coronary artery calcium (CAC) is a specific marker of coronary atherosclerosis that can be used to measure calcified subclinical atherosclerotic burden. The Agatston method is the most widely used scoring algorithm for quantifying CAC and is expressed as the product of total calcium area and a quantized peak calcium density weighting factor defined by the calcification attenuation in HU on noncontrast computed tomography. Calcium density has emerged as an important area of inquiry because the Agatston score is upweighted based on the assumption that peak calcium density and atherosclerotic cardiovascular disease (ASCVD) risk are positively correlated. However, recent evidence demonstrates that calcium density is inversely associated with lesion vulnerability and ASCVD risk in population-based cohorts when accounting for age and plaque area. Here, we review calcium density by focusing on 3 main areas: 1) CAC scan acquisition parameters; 2) pathophysiology of calcified plaques; and 3) epidemiologic evidence relating calcium density to ASCVD outcomes. Through this process, we hope to provide further insight into the evolution of CAC scoring on noncontrast computed tomography.

Sex-Specific Computed Tomography Coronary Plaque Characterization and Risk of Myocardial Infarction

OBJECTIVES

This study was designed to investigate whether coronary computed tomography angiography assessments of coronary plaque might explain differences in the prognosis of men and women presenting with chest pain.

BACKGROUND

Important sex differences exist in coronary artery disease. Women presenting with chest pain have different risk factors, symptoms, prevalence of coronary artery disease and prognosis compared to men.

METHODS

Within a multicenter randomized controlled trial, we explored sex differences in stenosis, adverse plaque characteristics (positive remodeling, low-attenuation plaque, spotty calcification, or napkin ring sign) and quantitative assessment of total, calcified, noncalcified and low-attenuation plaque burden.

RESULTS

Of the 1,769 participants who underwent coronary computed tomography angiography, 772 (43%) were female. Women were more likely to have normal coronary arteries and less likely to have adverse plaque characteristics (p < 0.001 for all). They had lower total, calcified, noncalcified, and low-attenuation plaque burdens (p < 0.001 for all) and were less likely to have a low-attenuation plaque burden >4% (41% vs. 59%; p < 0.001). Over a median follow-up of 4.7 years, myocardial infarction (MI) occurred in 11 women (1.4%) and 30 men (3%). In those who had MI, women had similar total, noncalcified, and low-attenuation plaque burdens as men, but men had higher calcified plaque burden. Low-attenuation plaque burden predicted MI (hazard ratio: 1.60; 95% confidence interval: 1.10 to 2.34; p = 0.015), independent of calcium score, obstructive disease, cardiovascular risk score, and sex.

CONCLUSIONS

Women presenting with stable chest pain have less atherosclerotic plaque of all subtypes compared to men and a lower risk of subsequent MI. However, quantitative low-attenuation plaque is as strong a predictor of subsequent MI in women as in men. (Scottish Computed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590).

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman's risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

Development and usability testing of HEARTPA♀N: protocol for a mixed methods strategy to develop an integrated smartphone and web-based intervention for women with cardiac pain

INTRODUCTION

More women experience cardiac pain related to coronary artery disease and cardiac procedures compared with men. The overall goal of this programme of research is to develop an integrated smartphone and web-based intervention (HEARTPA♀N) to help women recognise and self-manage cardiac pain.

METHODS AND ANALYSIS

This protocol outlines the mixed methods strategy used for the development of the HEARTPA♀N content/core feature set (phase 2A), usability testing (phase 2B) and evaluation with a pilot randomised controlled trial (RCT) (phase 3). We are using the individual and family self-management theory, mobile device functionality and pervasive information architecture of mHealth interventions, and following a sequential phased approach recommended by the Medical Research Council to develop HEARTPA♀N. The phase 3 pilot RCT will enable us to refine the prototype, inform the methodology and calculate the sample size for a larger multisite RCT (phase 4, future work). Patient partners have been actively involved in setting the HEARTPA♀N research agenda, including defining patient-reported outcome measures for the pilot RCT: pain and health-related quality of life (HRQoL). As such, the guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols (SPIRIT-PRO) are used to report the protocol for the pilot RCT (phase 3). Quantitative data (eg, demographic and clinical information) will be summarised using descriptive statistics (phases 2AB and 3) and a content analysis will be used to identify themes (phase 2AB). A process evaluation will be used to assess the feasibility of the implementation of the intervention and a preliminary efficacy evaluation will be undertaken focusing on the outcomes of pain and HRQoL (phase 3).

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Toronto (36415; 26 November 2018). We will disseminate knowledge of HEARTPA♀N through publication, conference presentation and national public forums (Café Scientifique), and through fact sheets, tweets and webinars.

TRIAL REGISTRATION NUMBER

NCT03800082.

Sex difference in fibrin clot lysability: Association with coronary plaque composition

INTRODUCTION

Fibrin clot lysability is associated with development of cardiovascular disease (CVD). We evaluated sex-differences in fibrin clot lysability and the association with coronary plaque composition determined by computed tomography angiography (CTA).

METHODS

Middle-aged citizens without known CVD were randomly selected from a national registry. A coronary CTA assessed volumes of calcified-, non-calcified-, low-density non-calcified-, and total- plaque using a validated plaque quantification software. A non-enhanced cardiac CT scan assessed the Agatston score. Fibrin structure properties were determined using turbidimetric methods. Plasma concentrations of C-reactive protein and fibrinogen were assessed.

RESULTS

138 individuals (71 women) participated. Men more frequently had coronary plaques compared to women, P < 0.05. Coronary plaque features were comparable between men and women, P > 0.05. Women with total plaque volume > 0 mm³ had lower fibrin clot lysability compared to women with total plaque volume = 0 mm³, adjusted difference [95% confidence interval] 10.28 [1.42-19.15], P = 0.02, and a fibrinogen-dependent lower fibrin clot lysability compared to men with and without coronary plaques, 6.82 [-2.67-16.31], P = 0.16, and 8.73 [-0.43-17.89], P = 0.06, respectively. Fibrinogen correlated with all the coronary plaque features (correlation coefficient r = 0.42-0.57) only in women with total plaque volume > 0 mm³, all P < 0.01.

CONCLUSION

Asymptomatic women with coronary plaques assessed by coronary CTA have reduced fibrin clot lysability compared to both women without coronary plaques and men, suggesting a sex-dependent link between coronary atherosclerosis and fibrin clot lysability.

Decreased Diagnostic Accuracy of Multislice Coronary Computed Tomographic Angiography in Women with Atypical Angina Symptoms

Background:

Multislice computed tomography (MSCT) coronary angiography (CAG) is a noninvasive technique with a reported high diagnostic accuracy for coronary artery disease (CAD). Women, more frequently than men, are known to develop atypical angina symptoms. The purpose of this study was to investigate whether the diagnostic accuracy of MSCT in women with atypical presentation differs from that in men.

Methods:

We enrolled 396 in-hospital patients (141 women and 255 men) with suspected or proven CAD who successively underwent both MSCT and invasive CAG. CAD was defined as any coronary stenosis of ≥50% on conventional invasive CAG, which was used as the reference standard. The patients were divided into typical and atypical groups based on their symptoms of angina pectoris. The diagnostic accuracy of MSCT, including its sensitivity, specificity, negative predictive value, and positive predictive value (PPV), was calculated to determine the usefulness of MSCT in assessing stenoses. The diagnostic performance of MSCT was also assessed by constructing receiver operating characteristic (ROC) curves.

Results:

The PPV (91% vs. 97%, χ² = 5.705, P < 0.05) and diagnostic accuracy (87% vs. 93%, χ² = 5.093, P < 0.05) of MSCT in detecting CAD were lower in women than in men. Atypical presentation was an independent influencing factor on the diagnostic accuracy of MSCT in women (odds ratio = 4.94, 95% confidence intervals: 1.16–20.92, Walds = 4.69, P < 0.05). Compared with those in the atypical group, women with typical angina pectoris had higher PPV (98% vs. 74%, χ² = 17.283. P < 0.001), diagnostic accuracy (93% vs. 72%, χ² = 9.571, P < 0.001), and area under the ROC curve (0.91 vs. 0.64, Z = 2.690, P < 0.01) in MSCT diagnosis.

Conclusions:

Although MSCT is a reliable diagnostic modality for the exclusion of significant coronary artery stenoses in all patients, gender and atypical symptoms might have some influence on its diagnostic accuracy.

Global Coronary Artery Plaque Area is Associated with Myocardial Hypoperfusion in Women with Non-ST Elevation Myocardial Infarction

BACKGROUND

Women with non-ST elevation myocardial infarction (NSTEMI) have similar extent of myocardial ischemia but less obstructive coronary artery disease (CAD) than their male counterparts. We tested the impact of global coronary artery plaque area and artery tortuosity on myocardial perfusion in NSTEMI patients.

METHODS

Coronary artery plaque area was determined by quantitative angiography in 108 patients (32% women) with NSTEMI. Myocardial perfusion was assessed by contrast echocardiography in the 17 individual left ventricular segments. Artery tortuosity was defined as ≥3 curves >45° in a main coronary artery.

RESULTS

Age, prevalence of hypertension, and diabetes did not differ between sexes (all nonsignificant). Women had lower prevalence of ≥50% coronary artery stenosis (74% vs. 91%, p<0.05), while global coronary plaque area (35±22 vs. 43±21mm(2)) and the number of segments with hypoperfusion (6.9±3.7 vs. 7.2±3.4) did not differ between sexes (both p>0.07). In multivariate analysis, larger coronary artery plaque area was associated with a 35% higher risk for having severe myocardial hypoperfusion (odds ratio 1.35 [95% confidence interval 1.01-1.80], p<0.05) in the total study population, while no association between artery tortuosity and myocardial ischemia was found. Similar results were obtained in separate analysis among women and men.

CONCLUSION

In women and men with NSTEMI, the global coronary artery plaque area was an important determinant of the severity of myocardial hypoperfusion at rest independent of presence of significant coronary stenoses. These findings may expand current understanding of NSTEMI in patients with nonobstructive CAD.

Coronary artery disease in patients with atypical chest pain with and without diabetes mellitus assessed with coronary CT angiography

INTRODUCTION

Coronary artery disease (CAD) in diabetes mellitus (DM) is often widespread when diagnosed. Non-invasive coronary calcium scoring and coronary CT angiography (CAC-score/CCTA) are accurate in the detection of CAD. This study compared CAD characteristics as identified by CCTA between patients with and without DM with atypical chest pain.

METHODS

CAD was defined as CAC-score >0 and/or presence of coronary plaque. Several CAD characteristics (number of affected segments, obstructive (>50% stenosis) CAD and CAD distribution) were compared on a per patient and segment basis. Subanalysis of duration of DM (<5 or >5 years) and gender was performed.

RESULTS

A total of 1148 patients (63.3% men, mean age 57.7±10.7), of whom 99 (8.6%) suffered from DM, were referred for CCTA. There was no difference in the prevalence of CAD between patients with and without DM (53.5% vs 50.9%, p=0.674). However patients with DM showed more affected coronary segments compared with patients without DM (2.5±3.4 vs 1.7±2.4, p=0.003). Multivariate analysis indicated that DM was an independent predictor of obstructive CAD (OR 2.16, 95% CI 1.23 to 3.78), as were age, women, and Diamond-Forrester score. In our study, obstructive CAD was more prevalent in women than in men (DM 40.0% vs 14.1%, p=0.003; non-DM 16.8% vs 8.4%, p<0.001). Patients suffering from DM >5 years showed more distal plaques (11.2% vs 7.7%, p=0.030).

CONCLUSIONS

Patients with atypical chest pain and DM showed more extensive CAD, as well as more obstructive CAD, particularly in women. Diabetes duration (>5 years) was not associated with more obstructive coronary disease or different plaque morphology, although more distal disease was present.