Leiden, The Netherlands—Heart attack risk is higher for postmenopausal women with clogged arteries than men of similar age, according to a new study. The researchers suggest that different medication regimens might be needed to adequately prevent the events.

The study was presented at the European Association of Cardiovascular Imaging (EACVI) 2023 Conference, a scientific congress of the European Society of Cardiology, and published in the European Heart Journal–Cardiovascular Imaging. Imaging techniques were used to examine the arteries and followed patients for heart attacks and death.

"The study suggests that a given burden of atherosclerosis is riskier in postmenopausal women than it is in men of that age," stated study author Sophie van Rosendael, MD, of Leiden University Medical Centre in The Netherlands. "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."

The researchers pointed out that by using coronary computed tomography angiography (CCTA), they can determine the level of atherosclerotic plaque to better determine the intensity of medical treatment required. Their study focused on differences in age onset and prognostic significance of atherosclerotic plaque burden between sexes.

With data from a large multicenter CCTA registry, the Leiden CCTA score was calculated in 24,950 individuals. Participants included 11,678 women with an average age of 58.5 years and 13,272 men with an average age of 55.6 years; they were followed for 3.7 years for major adverse cardiovascular events (MACE), including death or myocardial infarction.

"The age where the median risk score was above zero was 12 years higher in women vs. men (64-68 years vs. 52-56 years, respectively, P <.001)," the study team reports. "The Leiden CCTA risk score was independently associated with MACE: score 6-20: HR [hazard ratio] 2.29 (1.69-3.10); score >20: HR 6.71 (4.36-10.32) in women and score 6-20: HR 1.64 (1.29-2.08); score >20: HR 2.38 (1.73-3.29) in men."

The study found that the risk was significantly higher for women within the highest score group (adjusted P-interaction = .003). "In premenopausal women, the risk score was equally predictive and comparable with men. In postmenopausal women, the prognostic value was higher for women (score 6-20: HR 2.21 [1.57-3.11]; score >20: HR 6.11 [3.84-9.70] in women; score 6-20: HR 1.57 [1.19-2.09]; score >20: HR 2.25 [1.58-3.22] in men), with a significant interaction for the highest risk group (adjusted P-interaction = .004)," the researchers explained.

Coronary atherosclerosis develops approximately 12 years later in women than men. Still, the authors pointed out, "Postmenopausal women within the highest atherosclerotic burden group were at significantly higher risk for MACE than their male counterparts, which may have implications for the medical treatment intensity."

Women had more nonobstructive disease, according to the report, which also noted that the overall plaque burden as quantified by the Leiden CCTA score was significantly lower in women.

"The results confirm the previously reported delay in the start of atherosclerosis in women," Dr. van Rosendael said in an EACVI press release. "We also found that women are more likely to have non-obstructive disease. It was formerly thought that only obstructive atherosclerosis caused myocardial infarction, but we now know that nonobstructive disease is also risky."

Comparing postmenopausal women with those with a low burden, female participants with a medium and high burden were calculated to have 2.21-fold and 6.11-fold higher risks of MACE. In contrast, men aged 55 years and older compared with those with a low burden, those with a medium and high burden had 1.57-fold and 2.25-fold greater risks of MACE.

"In this study, the elevated risk for women versus men was especially observed in postmenopausal women with the highest Leiden CCTA score," Dr. van Rosenael added. "This could be partly because the inner diameter of coronary arteries is smaller in women, meaning that the same amount of plaque could have a larger impact on blood flow. Our findings link the known acceleration of atherosclerosis development after menopause with a significant increase in relative risk for women compared to men, despite a similar burden of atherosclerotic disease. This may have implications for the intensity of medical treatment."

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