Clinical Investigation
Acute Ischemic Heart Disease
Women have less severe and extensive coronary atherosclerosis in fatal cases of ischemic heart disease: An autopsy study

https://doi.org/10.1016/j.ahj.2010.12.022Get rights and content

Objective

The study aims to evaluate sex differences in extent and severity of coronary artery disease (CAD) and myocardial findings at autopsy among young people with fatal ischemic heart disease (IHD).

Background

Women with acute coronary syndrome are less likely than men to display obstructive CAD at angiography. This suggests unique mechanisms of acute coronary syndrome exist in women or may reflect prehospital death of women with the most severe CAD.

Methods

Reports of autopsies by the Office of the Chief Medical Examiner of New York City on people aged 21 to 54 years who died between January 1, 2006, and December 31, 2008, were reviewed. A total of 639 cases of death due to atherosclerotic or arteriosclerotic cardiovascular disease according to the medical examiner were analyzed. Significant CAD was defined as ≥75% cross-sectional area stenosis in an epicardial vessel or ≥50% left main.

Results

Women were less likely to have obstructive CAD (63% vs 77% of men, P = .002). There was pathologic evidence of myocardial infarction (MI) in 43% of cases, 17% of which had nonobstructive CAD. Frequency of MI did not vary by sex overall (38% of women vs 45% of men, P = .18) or among those without significant CAD (23% vs 29%, P = .45).

Conclusions

Among young people determined at autopsy to have died of IHD, fewer women had obstructive CAD, consistent with angiographic data in other IHD syndromes. Pathologic evidence of MI may exist in the absence of obstructive CAD.

Section snippets

Background

Across the spectrum of acute coronary syndromes (ACS), it is well established that women are less likely than men to display obstructive coronary artery disease (CAD) at angiography and often have angiographically normal coronaries.1, 2, 3, 4, 5 Reports of myocardial infarction (MI) in the setting of nonobstructive CAD have been documented with and without vasospastic agents in both sexes over the past 6 decades.6, 7, 8, 9 This suggests that, transient mechanisms of coronary occlusion may be

Methods

Reports of autopsies conducted by the Office of Chief Medical Examiner (OCME) of the city of New York on all women and men aged 21 to 54 years between January 1, 2006, and December, 31, 2008, were reviewed and selected when atherosclerotic or arteriosclerotic cardiovascular disease (CVD), with or without hypertensive CVD, was listed as the underlying cause of death. These causes of death as determined at autopsy are counted as IHD deaths for the purposes of vital statistics reporting.17 Cases

Demographics

There were 1,686 cases determined to have a cardiovascular cause of death among all consecutive cases aged 21 to 54 years during the study period, of which 639 (128 women and 511 men) met inclusion criteria (see Figure 1). Among those decedents aged 21 to 54 who died in natural manner from a cardiovascular cause, a lower proportion of women were determined to have died of IHD (214 women [49.3%] vs 783 men [66.1%], P < .001). An equal proportion of these women and men underwent full autopsy

Discussion

This autopsy study found that among young people who died of ischemic heart disease, women had less severe and extensive CAD than men, consistent with findings of angiographic studies in patients with ACS and stable chest pain syndromes.1, 2, 3, 4, 5 This suggests that women have less severe atherosclerotic disease than men, across the full clinical spectrum of IHD. As is well known from prior studies, MI does occur in patients with nonobstructive CAD and even with normal coronary arteries. We

Study limitations

Despite the benefits of pathologic review, there is an inherent bias in the selection of cases for autopsy.32, 33 Cases in this series were selected for autopsy because of uncertainty in the reason for death. It is possible that some decedents with known, severe CAD dying out of hospital were not selected for autopsy, but based on OCME routine in NYC, the number of such cases is likely to be small. We cannot exclude bias in this selection based on sex (ie, women who die suddenly may be selected

Conclusions

Young women determined at autopsy to have died of IHD are less likely than men of similar age to have ≥75% cross-sectional area coronary stenosis in any major epicardial vessel. Pathologic evidence of MI in the absence of ≥75% CSA stenosis of a coronary artery was common in this cohort of consecutive cases determined at autopsy to have died of IHD in natural manner. Among decedents with at least one ≥75% CSA stenosis, there was no sex difference in the extent and severity of stenosis.

Disclosures

The authors are solely responsible for the design and conduct of this study, all study analyses, and the drafting and editing of the manuscript and its final contents.

Acknowledgements

We thank Sandeep Mangalmurti, MD, for his assistance with data extraction.

References (37)

  • SchmermundA. et al.

    Coronary atherosclerosis in unheralded sudden coronary death under age 50: histo-pathologic comparison with “healthy” subjects dying out of hospital

    Atherosclerosis

    (2001)
  • PepineC.J. et al.

    Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE study

    J Am Coll Cardiol

    (2010)
  • TargonskiP. et al.

    Referral to autopsy: effect of antemortem cardiovascular disease: a population-based study in Olmsted County, Minnesota

    Ann Epidemiol

    (2001)
  • NishiokaT. et al.

    Clinical validation of intravascular ultrasound imaging for assessment of coronary stenosis severity: comparison with stress myocardial perfusion imaging

    J Am Coll Cardiol

    (1999)
  • BriguoriC. et al.

    Intravascular ultrasound criteria for the assessment of the functional significance of intermediate coronary artery stenoses and comparison with fractional flow reserve

    Am J Cardiol

    (2001)
  • ServossS.J. et al.

    Triggers of acute coronary syndromes

    Prog Cardiovasc Dis

    (2002)
  • HochmanJ.S. et al.

    Sex, clinical presentation, and outcome in patients with acute coronary syndromes. GUSTO IIb Investigators

    N Engl J Med

    (1999)
  • ChokshiN.P. et al.

    Sex and race are associated with the absence of epicardial coronary artery obstructive disease at angiography in patients with acute coronary syndromes

    Clin Cardiol

    (2008)
  • Cited by (70)

    • Cardiovascular Imaging in Women

      2024, Seminars in Nuclear Medicine
    • Diagnostic Value of Cardiac Magnetic Resonance Imaging and Intracoronary Optical Coherence Tomography in Patients With a Working Diagnosis of Myocardial Infarction With Non-obstructive Coronary Arteries – A Systematic Review and Meta-analysis

      2023, Current Problems in Cardiology
      Citation Excerpt :

      Non-atherosclerotic causes include coronary spasm, coronary embolism, endothelial dysfunction, spontaneous coronary artery dissection and conditions causing myocardial oxygen supply-demand imbalance (such as Severe Hypertension, anemia, arrhythmias, hypotension).10 Studies have shown that the 4-year rate of major adverse cardiac events (MACE) following MINOCA was around 25%, and the 5-year mortality was around 11% which is comparable to MI of obstructive coronary disease, and it is important to establish the diagnosis and manage accordingly.11-13 The major roadblock in diagnosing MINOCA is to exclude other conditions that mimic acute MI (such as myocarditis, takotsubo syndrome, cardiomyopathy, etc.), and this requires the use of advanced imaging modalities like cardiac magnetic resonance (CMR).

    • Ischemic Heart Disease in Young Women: JACC Review Topic of the Week

      2022, Journal of the American College of Cardiology
      Citation Excerpt :

      Approximately one-half of MINOCA patients are aged <60 years at the time of MI, and ∼25% present at <50 years.1 Outcomes among MINOCA patients are better than in MI-CAD,27 but MINOCA may present as a fatal event.28 Recurrent MI occurs in ∼7% of MINOCA patients over 4 years, but only about one-half of recurrent MIs present as MINOCA.29

    • Women: Diet, Cardiometabolic Health, and Functional Medicine

      2022, Physical Medicine and Rehabilitation Clinics of North America
    View all citing articles on Scopus
    View full text