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

Michelle C. Williams (Lead / Corresponding author), Jacek Kwiecinski, Mhairi Doris, Priscilla McElhinney, Michelle S. D’Souza, Sebastien Cadet, Philip D. Adamson, Alastair J. Moss, Shirjel Alam, Amanda Hunter, Anoop S. V. Shah, Nicholas L. Mills, Tania Pawade, Chengjia Wang, Jonathan R. Weir Mccall, Michael Bonnici-Mallia, Christopher Murrills, Giles Roditi, Edwin J. R. Van Beek, Leslee J. ShawEdward D. Nicol, Daniel S. Berman, Piotr J. Slomka, David E. Newby, Marc R. Dweck, Damini Dey

    Research output: Contribution to journalArticlepeer-review

    31 Citations (Scopus)


    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).

    Original languageEnglish
    Pages (from-to)1804-1814
    Number of pages11
    JournalJACC: Cardiovascular Imaging
    Issue number9
    Early online date14 Apr 2021
    Publication statusPublished - Sept 2021


    • computed tomography
    • computed tomography coronary angiography
    • coronary artery disease
    • quantitative plaque analysis
    • sex

    ASJC Scopus subject areas

    • Radiology Nuclear Medicine and imaging
    • Cardiology and Cardiovascular Medicine


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