- Open Access
Sex differences in coronary angiographic findings in patients with stable chest pain: analysis of data from the KoRean wOmen’S chest pain rEgistry (KoROSE)
Biology of Sex Differences volume 13, Article number: 2 (2022)
Focused evaluations on potential sex differences in the angiographic findings of the coronary arteries are scarce. This study was performed to compare the angiographic extent and localization of coronary stenosis between men and women.
A total of 2348 patients (mean age 62.5 years and 60% women) with stable chest pain undergoing invasive coronary angiography (CAG) were recruited from the database of the nation-wide chest pain registry. Obstructive coronary artery disease (CAD) was defined as ≥ 50% stenosis of the left main coronary artery and/or ≥ 70% stenosis of any other epicardial coronary arteries.
Although women were older than men (64.4 ± 10.3 vs. 59.5 ± 11.4 years, P < 0.001), men had worse risk profiles including high blood pressure, more frequent smoking and elevated triglyceride and C-reactive protein. The prevalence of obstructive CAD was significantly higher in men than in women (37.0% vs. 28.4%, P < 0.001). Men had a higher prevalence of LM disease (10.3% vs. 3.5%, P < 0.001) and three-vessel disease (16.1% vs. 9.5%, P = 0.007) compared to women. In multiple binary logistic regression analysis, the risk of men having LM disease or three-vessel disease was 7.4 (95% confidence interval 3.48–15.97; P < 0.001) and 2.7 (95% confidence interval 1.57–4.64; P < 0.001) times that of women, respectively, even after controlling for potential confounders.
In patients with chest pain undergoing invasive CAG, men had higher obstructive CAD prevalence and more high-risk angiographic findings such as LM disease or three-vessel disease.
Focused evaluation on sex differences in the angiographic findings of the coronary arteries is limited.
We evaluated sex differences in the angiographic extent and localization of coronary stenosis in 2348 patients.
Men had higher prevalence of obstructive coronary artery disease and more high-risk angiographic findings such as left main disease or three-vessel disease.
This sex difference could be applied in the clinical evaluation and management of patients with suspected coronary artery disease.
Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. With improvement in diagnostic and therapeutic tools, the prognosis of patients with CAD has been much improved. However, the prevalence of CAD is still high, and the complications associated with CAD are the number one cause of human death [1,2,3] Therefore, in order to improve patients’ prognosis and reduce the enormous medical cost, it is important to find CAD patients earlier and perform customized treatment. For rapid CAD diagnosis and effective treatment, understanding pathophysiology underlying in CAD development should be the basis. Human efforts to understand sex differences in the cardiovascular field, and to apply them in clinical practice have continued [4,5,6]. In CAD, sex differences in several points such as clinical presentation and prognosis are relatively well evaluated. However, little is known regarding potential sex differences in the angiographic findings of coronary arteries. Since invasive coronary angiography (CAG) is the reference standard for CAD diagnosis, understanding sex difference in invasive CAG findings is valuable for the management of patients with CAD. Therefore, this study was performed to compare the extent and localization of coronary stenosis on invasive CAG between men and women.
Materials and methods
We analyzed data from the nation-wide prospective registry database, the KoRean wOmen’S chest pain rEgistry (KoROSE), which was constructed to investigate clinical characteristics and outcomes of Korean women with suspected CAD in a stable state. For comparison, men were also registered in the registry. Many research articles using this registry data have already been published [7,8,9]. Collection of this registry data began in February 2011, and patient registration is still ongoing. Currently, 22 cardiovascular centers in Korea are participating in this registry. The patients enrolled were Korean adult men and women over the age of 20 years who complained of chest pain and underwent invasive CAG because of suspected CAD. Because study enrollment was based on relatively stable patients who visited the outpatient clinic, patients with acute coronary syndrome were excluded. In most cases, tests such as treadmill exercise test, coronary computed tomography angiography, single-photon emission computed tomography, and dobutamine stress echocardiography were performed according to the patient’s renal function and functional capacity. Invasive CAG was performed according to these results of non-invasive tests. After invasive CAG, attending physician explained the study protocol and enrolled patients who agreed to participate in the registry. The Institutional Review Board of Boramae Medical Center (Seoul, South Korea) approved registry registration, and the use of the registered data for research purposes. All patients were given written consent for registry registration.
Clinical data were obtained at the time of admission for invasive CAG. Body mass index was the body weight (kg) divided by the height squared (m2). Body mass index ≥ 25 kg/m2 was considered obese . Waist circumference was measured with a tape measure. A tape measure was placed in the middle of the lowest position of the ribs and the highest position of the pelvis during expiration. Systolic/diastolic blood pressure and heart rate were measured by a trained nurse using an automatic oscillometric device. Hypertension was defined on the basis of (1) previous diagnosis of hypertension by a physician; (2) current anti-hypertensive medications, or (3) systolic/diastolic blood pressure ≥ 140/90 mmHg in repeated measurements. Diabetes mellitus was defined on the basis of (1) previous diagnosis of diabetes mellitus by a physician; (2) current anti-diabetic medications, or (3) fasting blood glucose level ≥ 126 mg/dL in repeated tests. Dyslipidemia was defined on the basis of (1) previous diagnosis of dyslipidemia by a physician; (2) current anti-dyslipidemic medications, or (3) low-density lipoprotein cholesterol ≥ 160 mg/dL. A person who smoked regularly within the last 12 months was defined as a smoker. After overnight fasting, blood levels of the following laboratory parameters were obtained: white blood cell count, hemoglobin, creatinine, glucose, glycated hemoglobin, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C), triglyceride, and C-reactive protein. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease (MDRD) Study equation. Information on concomitant cardiovascular medications including antiplatelets, calcium channel blocker, beta-blocker, renin–angiotensin system blocker, and statin was also obtained.
Invasive CAG was performed using a radial or femoral artery in accordance with current guidelines [11, 12]. All management strategies for CAD, including coronary revascularization, were chosen at the discretion of the attending physician. An obstructive CAD was defined as any ≥ 50% stenosis of the left main coronary artery, ≥ 70% stenosis of any other epicardial coronary arteries, or both. The extent of CAD was classified as one‐, two‐, or three‐vessel disease. Significant left main stenosis (≥ 50%) was considered as two-vessel diseases. The coronary artery was divided into 17 segments, and we obtained information on the maximum stenosis of each segment [13, 14]. Left main disease or three-vessel disease were considered as a high-risk finding.
Continuous variables are expressed as mean ± standard deviation, and categorical variables are expressed as n (%). Student’s t test was used to compare continuous variables and the Chi-square test was used to compare categorical variables between two groups. Binary logistic regression analyses were performed to investigate independent associations between sex and angiographic findings. During multivariable analyses the following potential confounders were controlled: age, body mass index, hypertension, diabetes mellitus, dyslipidemia, smoking and renal function. A P value of < 0.05 was considered statistically significant. All statistical analyses were conducted using SPSS version 21.0 (IBM Crop., Armonk, NY, USA).
Clinical characteristics of the study patients
Nine hundred and forty-one men and 1407 women (59.9%) were analyzed in this study. Comparisons of clinical characteristics between men and women are demonstrated in Table 1. Women were older than men (64.4 ± 10.3 vs. 59.5 ± 11.4 years, P < 0.001). Mean body mass index was similar between men and women, but waist circumference was greater in men than in women. Both systolic and diastolic blood pressures were higher in men than in women. Among traditional cardiovascular risk factors, the proportions of smokers and obesity were higher in men than in women. In laboratory findings, women had lower blood hemoglobin, triglycerides and C-reactive protein levels as well as higher total cholesterol and high-density lipoprotein cholesterol levels than men. Among cardiovascular medications, beta-blockers and statin were more frequently prescribed in women than in men.
About one-third of patients (31.8%) had obstructive CAD. Comparisons of clinical characteristics between patients with and without obstructive CAD in men and women are shown in Table 2. Patients with obstructive CAD were older in both men (62.6 ± 10.2 vs. 57.0 ± 11.6 years, P < 0.001) and women (68.1 ± 9.1 vs. 62.4 ± 10.3 years, P < 0.001). Patients with obstructive CAD had more cardiovascular risk factors such as hypertension, diabetes and smoking than those without in both sexes. Laboratory findings also showed worse profiles including higher levels of white blood cell count, fasting glucose and low-density lipoprotein cholesterol as well as lower levels of hemoglobin, glomerular filtration rate, and high-density lipoprotein cholesterol in patients with obstructive CAD than in those without in both men and women. Antiplatelets, beta-blocker, renin–angiotensin system blocker and statin were more frequently prescribed to patients with obstructive CAD than those without in both sexes.
Sex differences in angiographic findings
Angiographic findings of men and women in the total study population are demonstrated in Table 3. The prevalence of obstructive CAD was significantly higher in men than in women (37.0% vs. 28.4%, P < 0.001) (Fig. 1). Two- or three-vessel disease or LM disease was more prevalent in men than in women (16.0% vs. 11.2%, P ≤ 0.001). In addition to the three major epicardial coronary arteries, significant stenosis of the branch arteries was also prevalent in men, compared to women. LM disease with proximal LAD significant stenosis or LM with proximal significant stenosis of at least one of three major epicardial coronary arteries were more frequently observed in men than in women. Even when we considered only patients with obstructive CAD, men had more three-vessel disease or LM disease than in women (P < 0.05 for each) (Fig. 2). Significant stenosis of the RCA and branched coronary arteries were more prevalent in men than in women (Table 4). Being a man itself was an independent factor predicting obstructive CAD (OR [odds ratio] 1.48; 95% CI [confidence interval] 1.17–1.86; P = 0.001), LM disease (OR 7.46; 95% CI 3.48–15.98; P < 0.001), LM disease with proximal LAD significant stenosis (OR 1.51; 95% CI 1.16–1.98; P = 0.002), and three-vessel disease (OR 2.70; 95% CI 1.57–4.64; P < 0.001), even though various clinically important covariates were corrected (Table 5). Besides male sex, old age was associated with LM disease, and old age, hypertension and diabetes mellitus were associated with three-vessel disease even after controlling for potential confounders (Additional file 1: Table S1).
Using a nation-wide registry database, we attempted to find out the sex differences of invasive CAG findings in patients who had chest pain in a stable state. Our results showed several important findings: (1) despite younger age, men more frequently had risk factors for cardiovascular disease than women, which resulted in a higher obstructive CAD prevalence in men; (2) men more frequently had LM disease or three-vessel disease than women, and (3) these sex differences persisted even after controlling for important clinical covariates.
Previous similar studies
The summary of previous studies investigating sex differences in CAG findings is demonstrated in Table 6. Numerous studies have reported that angiographically documented CAD is more severe in men than in women [15,16,17,18,19,20,21,22]. These findings are concordant with ours showing that compared to women, men had more burden of obstructive CAD. However, our study has several differences and strengths compared to the previous studies. Most of the existing studies were conducted in the Western countries. If we consider ethnic differences in cardiovascular disease , our study of Koreans is valuable. Our study provides an additional result that in Asians like Westerners, men more frequently have CAD than women. Considering very low proportion of women in previous studies, higher proportion of women was another strength of this study. In addition, the primary research goal in most studies was to determine if there were sex differences in subsequent management and clinical outcomes following CAG. Therefore, only sex differences in CAG findings were demonstrated briefly, and more specific analysis on lesion location were not shown in most studies. Only one study focused primarily on sex differences in angiographic findings, and showed specific CAD locations . Moreover, only a few studies have performed multivariable analysis to demonstrate whether sex is an independent factor associated with CAD severity [18, 22]. In our study, the primary aim was to determine the differences in CAG findings between men and women. In addition, we analyzed the detailed lesion location of CAD, and also performed multivariable analysis to evaluate the effect of sex on CAD severity after adjustment for confounding factors. Although not the majority opinion, some other studies have shown that there is no sex difference in the extent and localization of coronary angiographic lesions [24,25,26,27]. Further studies are needed to reach a firmer conclusion on sex difference in the severity and extent of angiographic CAD.
In our study, higher blood pressure, greater proportions of smokers and obese patients, and worse lipid profiles could explain more significant and extensive CAD in men than in women. Although women were older than men, they less frequently had cardiovascular risk factors than men. Indeed, in addition to old age and male sex, traditional cardiovascular risk factors including hypertension and diabetes mellitus were significantly associated with the presence of three-vessel disease in our multivariable analysis. However, old age and male sex were only factors associated with LM disease, and the risk of male sex itself was higher than age. It can be assumed that male sex itself had a great influence on LM disease, and cardiovascular risk factors, which have a high prevalence in men, contributed to the development of three-vessel disease. Cardiovascular system protection by female sex hormone may be a commonly proposed reason for lower risk profiles in women . In our study, women had higher HDL-C than men, and those with CAD had significantly lower HDL-C than those without CAD. This result suggests that HDL-C probably played an important role in CAD development and progression , and induced sex differences.
Our results of Asian patients did not differ significantly from the main finding of the existing Western studies indicating that men had a more severe angiographically documented CAD than women. We should always be aware of the high risk of male sex itself when treating patients. In other words, since women generally develop less coronary artery pathology compared to men at the same age, women with CAD represent a vulnerable subgroup and need special attention. In addition, given that men have more severe and extensive CAD, one can expect that women have less symptoms and better prognosis; however, previous studies have shown opposite findings . As ischemia and ischemia-like symptoms are not solely related to the severity of atherosclerosis, we should not overlook the fact that coronary microvascular dysfunction or coronary spasm are a more common cause of stable ischemic heart disease in women [5, 6, 26].
We acknowledge several limitations of the present study. First, coronary stenosis was visually evaluated in our study. If we had performed quantitative coronary analysis, more accurate data could have been obtained. Second, in our study, no intravascular evaluation or computed tomographic examination was performed, so we could not analyze differences between men and women in coronary plaque properties [4, 5, 31]. Third, the hemodynamical significance of CAD was not evaluated in our study. Lastly, since all subjects of our study were Koreans and patients with stable chest pain, it would be difficult to apply our results directly to other ethnic groups or patients with acute coronary syndrome.
Perspectives and significance
Among Korean patients with chest pain in a stable state, men had more extensive and severe angiographic CAD compared to women even at younger ages. More critical CAD including LM disease and three-vessel disease were also more prevalent in men. We need to understand this observed sex differences, which could apply in the clinical evaluation and management of patients with suspected CAD. Specifically, since men are more likely to have severe CAD, it is desirable to recommend more active tests and intensified management to men with suspected CAD.
Availability of data and materials
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141:e139–596.
GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1736–88.
Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyuet G, et al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol. 2017;70:1–25.
Mosca L, Barrett-Connor E, Wenger NK. Sex/gender differences in cardiovascular disease prevention: what a difference a decade makes. Circulation. 2011;124:2145–54.
Gerdts E, Regitz-Zagrosek V. Sex differences in cardiometabolic disorders. Nat Med. 2019;25:1657–66.
Shaw LJ, Bugiardini R, Merz CN. Women and ischemic heart disease: evolving knowledge. J Am Coll Cardiol. 2009;54:1561–75.
Cho JH, Kim HL, Kim MA, Oh S, Kim M, Park SM, et al. Association between obesity type and obstructive coronary artery disease in stable symptomatic postmenopausal women: data from the KoRean wOmen’S chest pain rEgistry (KoROSE). Menopause. 2019;26:1272–6.
Kim HL, Kim MA, Shim WJ, Oh S, Kim M, Park SM, et al. Sex difference in the association between brachial pulse pressure and coronary artery disease: the Korean Women’s Chest Pain Registry (KoROSE). J Clin Hypertens. 2017;19:38–44.
Kim HL, Kim MA, Shim WJ, Park SM, Kim YH, Na JO, et al. Reproductive factors predicting angiographic obstructive coronary artery disease: the KoRean wOmen’S Chest Pain rEgistry (KoROSE). J Women’s Health. 2016;25:443–8.
Seo MH, Lee WY, Kim SS, Kang JH, Kang JH, Kim KK, et al. 2018 Korean Society for the study of obesity guideline for the management of obesity in Korea. J Obes Metab Syndr. 2019;28:40–5.
Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, et al. ACC/AHA guidelines for coronary angiography: executive summary and recommendations. Circulation. 1999;99:2345–57.
Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;64:1929–49.
Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105:539–42.
Austen WG, Edwards JE, Frye RL, Gensini GG, Gott LV, Griffith LS, et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation. 1975;51:5–40.
Giannoglou GD, Antoniadis AP, Chatzizisis YS, Damvopoulou E, Parcharidis GE, Louridas GE. Sex-related differences in the angiographic results of 14,500 cases referred for suspected coronary artery disease. Coron Artery Dis. 2008;19:9–14.
Gudnadottir GS, Andersen K, Thrainsdottir IS, James SK, Lagerqvist B, Gudnason T. Gender differences in coronary angiography, subsequent interventions, and outcomes among patients with acute coronary syndromes. Am Heart J. 2017;191:65–74.
Ouellette ML, Löffler AI, Beller GA, Workman VK, Holland E, Bourque JM. Clinical characteristics, sex differences, and outcomes in patients with normal or near-normal coronary arteries, non-obstructive or obstructive coronary artery disease. J Am Heart Assoc. 2018. https://doi.org/10.1161/JAHA.117.007965.
Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Andersonet HV, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362:886–95.
Ritsinger V, Hero C, Svensson AM, Saleh N, Lagerqvist B, Eeg-Olofssonet K, et al. Characteristics and prognosis in women and men with type 1 diabetes undergoing coronary angiography: a nationwide registry report. Diabetes Care. 2018;41:876–83.
Chiha J, Mitchell P, Gopinath B, Plant AJH, Kovoor P, Thiagalingamet A, et al. Gender differences in the severity and extent of coronary artery disease. Int J Cardiol Heart Vasc. 2015;8:161–6.
Bell MR, Berger PB, Holmes DR Jr, Mullany CJ, Bailey KR, Gersh BJ. Referral for coronary artery revascularization procedures after diagnostic coronary angiography: evidence for gender bias? J Am Coll Cardiol. 1995;25:1650–5.
Tamis-Holland JE, Lu J, Bittner V, Lopes N, Adler DS, Kip KE, et al. Sex, clinical symptoms, and angiographic findings in patients with diabetes mellitus and coronary artery disease. J Am Coll Cardiol. 2011;107:980–5.
Chaturvedi N. Ethnic differences in cardiovascular disease. Heart. 2003;89:681–6.
Roeters van Lennep JE, Zwinderman AH, Roeters van Lennep HW, Westerveld HE, Plokker HW, Voors AA, et al. Gender differences in diagnosis and treatment of coronary artery disease from 1981 to 1997. No evidence for the Yentl syndrome. Eur Heart J. 2000;21:911–8.
Leaf DA, Sanmarco ME, Bahl RA. Gender differences in coronary angiographic findings from 1972 through 1981 in Los Angeles, California. Angiology. 1990;41:609–15.
Kyriakidis M, Petropoulakis P, Androulakis A, Antonopoulos A, Apostolopoulos T, Barbetseas J, et al. Sex differences in the anatomy of coronary artery disease. J Clin Epidemiol. 1995;48:723–30.
Kim CH, Koo BK, Lee JM, Shin ES, Park J, Choi KH, et al. Influence of sex on relationship between total anatomical and physiologic disease burdens and their prognostic implications in patients with coronary artery disease. J Am Heart Assoc. 2019;8:e011002.
Iorga A, Cunningham CM, Moazeni S, Ruffenach G, Umar S, Eghbali M. The protective role of estrogen and estrogen receptors in cardiovascular disease and the controversial use of estrogen therapy. Biol Sex Differ. 2017;8:33.
Huxley RR, Barzi F, Lam TH, Czernichow S, Fang X, Welborn T, et al. Isolated low levels of high-density lipoprotein cholesterol are associated with an increased risk of coronary heart disease: an individual participant data meta-analysis of 23 studies in the Asia-Pacific region. Circulation. 2011;124:2056–64.
Shaw LJ, Shaw RE, Merz CN, Brindis RG, Klein LW, Nallamothu B, et al. Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American College of Cardiology-National Cardiovascular Data Registry. Circulation. 2008;117:1787–801.
Bharadwaj AS, Vengrenyuk Y, Yoshimura T, Baber U, Hasan C, Narul J, et al. Multimodality intravascular imaging to evaluate sex differences in plaque morphology in stable CAD. JACC Cardiovasc Imag. 2016;9:400–7.
The authors would like to thank investigators who participated in the KoRean wOmen’S chest pain rEgistry (KoROSE).
This research received no grant from any funding agency in the public, commercial or not-for-profit sectors.
Ethics approval and consent to participate
The study protocol complied with the Declaration of Helsinki, and was approved by the Institutional Review Board of each participating hospital. Written informed consent was obtained from each patient.
Consent for publication
The authors declare that there is no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Additional file 1.
Table S1. Multiple binary logistic regression analyses showing independent predictors for LM disease and three vessel disease.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Kim, HL., Kim, HJ., Kim, M. et al. Sex differences in coronary angiographic findings in patients with stable chest pain: analysis of data from the KoRean wOmen’S chest pain rEgistry (KoROSE). Biol Sex Differ 13, 2 (2022). https://doi.org/10.1186/s13293-021-00411-1
- Coronary angiography
- Coronary artery disease
- Left main disease
- Sex differences
- Three-vessel disease