Insights Into Coronary Plaque Microstructure Differences Between Women and Men

> The difference between men and women is getting harder and harder to invent. > > —Marty Rubin Cardiovascular disease remains the leading cause of death in men and women in the United States. Over the past 2 decades, both clinicians and researchers have paid increased attention to the problem of cardiovascular disease in women, with some improvements in the recognition of the problem and in outcomes. Historically, women with acute coronary syndrome (ACS) have had worse outcomes. However, with the improvement in the availability of revascularization and application of guideline-directed therapies for both sexes, the gap in outcomes between men and women has been closing.1See Article by Kataoka et al During the same period of time, we have learned more about the sex differences in cardiovascular risk factor profiles, coronary anatomy, and physiology. Women presenting with symptomatic coronary artery disease (CAD) tend to have larger burden of cardiovascular risk factors, especially of current smoking and metabolic syndrome, and a higher Framingham Risk Score.2 Coronary atherosclerosis in women is characterized not only by smaller plaque burden but also by smaller size of coronary arteries.1–6 Therefore, due to smaller luminal size women may develop symptoms even with smaller plaque burden or thrombus load. The observational studies that examined coronary plaque morphology differences in men and women have been far from conclusive, some suggesting lower prevalence of plaque ruptures and thin-cap fibroatheroma (TCFA), higher prevalence of plaque erosions in women and others showing no significant differences.4,7–10 Interestingly, the sex differences in plaque size and morphology were more pronounced in younger patients and attenuated in patients >65 years of age.2,10 In addition to coronary plaque morphology, there were also differences in coronary flow characteristics, with women having higher fractional flow reserve values …