Scientists Find Sneaky Heart Attack Risk Factor in Women

Heart disease is the leading cause of death in America, making prevention crucial. But new research suggests there’s a heart attack risk factor that women face. A study found that women may experience heart attacks and major adverse cardiovascular events (MACE) with lower levels of plaque buildup in their arteries than men.

The study, which was published in the journal Circulation: Cardiovascular Imaging, is raising a lot of questions about heart disease prevention in women and whether more intensive interventions are needed.

For the study, researchers analyzed data from nearly 4,300 people with no known prior coronary artery disease who sought help for chest pain. The researchers analyzed computed tomography angiography (CCTA) images that measured total plaque volume and total plaque burden (TPB), or the amount of plaque relative to the size of the blood vessel. (Plaque is a waxy buildup of cholesterol, fat, calcium, and more that accumulates inside the arteries. Plaque buildup restricts blood flow and raises the risk of heart attack and stroke.)

Meet the experts: Kevin Shah, M.D., cardiologist and program director of heart failure outreach at MemorialCare Heart & Vascular Institute at Long Beach Medical Center in Long Beach, CA; Navjot Sobti, M.D., interventional cardiologist and women’s heart health specialist at Northwell’s Northern Westchester Hospital and Katz Institute for Women’s Health

While the researchers found that women had lower amounts of plaque than men and less plaque with characteristics that were considered high-risk, they still had similar rates of major adverse cardiovascular events over 26 months compared to men. To put it more plainly, women, heart risk in genetic women rose when plaque burden reached 20%, whereas in men, it rose when it reached 28%.

The risk of major adverse cardiovascular events increased more steeply at lower levels of plaque than men, while the risk of these cardiovascular events increased more gradually in men and required higher levels of plaque.

The researchers wrote in the study’s conclusion that the findings suggest there should be “sex-specific interpretation” of plaque measurements for “timely intervention” in women.

So, why does this happen, and what does it suggest for heart disease prevention in genetic women? Here’s what cardiologists want you to know.

Why might women have a higher risk of cardiovascular events with lower levels of plaque?

The exact reason for this isn’t clear. While the study found that women were more likely to have the same risk of major cardiovascular events at lower levels of plaque buildup, it didn’t explore why.

“The theory is that females, on average, are smaller than males, and their heart sizes are smaller,” says Kevin Shah, M.D., cardiologist and program director of heart failure outreach at MemorialCare Heart & Vascular Institute at Long Beach Medical Center in Long Beach, CA. “But the actual metric with plaque volume tries to adjust for the size of the blood vessels.” Because of that, Dr. Shah says it’s “hard to chalk it up to the size of the person or the size of their heart.”

But heart disease tends to show up differently in women, points out Navjot Sobti, M.D., interventional cardiologist and women’s heart health specialist at Northwell’s Northern Westchester Hospital and Katz Institute for Women’s Health. “Additionally, women have been historically underrepresented in cardiovascular research,” Dr. Sobti says. “Many risk thresholds and imaging cutoffs were developed using male populations and focus on finding large artery blockages a.k.a. ‘obstructive disease,’ but women are more likely to have non-obstructive disease and types of heart attacks that don’t show large blockages on heart imaging.”

In many cases, women develop heart attacks or heart disease from issues like coronary artery spasm, a spontaneous coronary artery tear or dissection (SCAD), or problems in the heart’s small blood vessels—conditions that don’t show up as major blockages and are often missed by traditional heart disease risk models, Dr. Sobti explains.

“As a result, women can have serious heart events at lower levels of visible plaque, highlighting the limitations of a one-size-fits-all approach and the need for sex-specific risk assessment and prevention strategies,” she says. “Sex-specific risk assessment matters.”

How can I lower my risk of a heart attack?

Everyone should follow the American Heart Association (AHA)’s Life’s Essential eight, which are steps designed to improve and maintain cardiovascular health, Dr. Shah says. “But there should be a greater emphasis on these if a female patient has some plaque volume detected,” he says. Even mild coronary plaque in women may increase the need for earlier and more aggressive prevention methods, like statins, blood pressure control, and lifestyle interventions, along with proactive screening like coronary calcium scoring, Dr. Sobti says.

While a conversation with your cardiologist is essential, here’s what the AHA suggests people do to lower their risk of heart disease:

The bottom line

While more research is needed, experts say these findings are meaningful. Dr. Shah says that “this is an important finding,” noting that more cardiologists are scanning patients for plaque buildup. “These studies inform us that men and women are different in terms of plaque,” he says. As always, consult your physician for more tailored recommendations.