Clinical InvestigationAcute Ischemic Heart DiseaseWomen have less severe and extensive coronary atherosclerosis in fatal cases of ischemic heart disease: An autopsy study
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.
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