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  • Meta-Analysis: Men May Have Larger, More Pronounced Carotid Atherosclerotic Plaques

    A new meta-analysis suggests there may be sex differences in carotid atherosclerosis. Overall, men had more and larger plaques, and these plaques had more features than those in women, the analysis shows.

    This information was reported by Dianne H.K. van Dam-Nolen, MD, of Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues in a manuscript published Monday online and in a special issue of Stroke focused on cerebrovascular diseases in women, published in conjunction with the American Heart Association’s Go Red for Women initiative

    It is estimated that 10% to 15% of all ischemic strokes are caused by carotid atherosclerosis. Men are at greater risk for ischemic stroke over a lifetime, and are more likely to have large-artery related atherosclerosis, than women. Women are more likely to experience cardioembolic strokes. Women are also at higher risk for perioperative stroke and death, and benefit less from surgery overall.

    Various studies have tackled the question of sex differences in carotid atherosclerosis, addressing symptomatic vs. nonsymptomatic patients, mild vs. severe cases and overall assessment of plaques in the disease. This study focused on reviewing the literature on sex differences in carotid atherosclerosis and providing a comprehensive summary of the findings.

    PubMed, Embase, Web of Science, Cochrane Central and Google Scholar were used to find the 42 studies analyzed in this review. The studies had to include reports of calcifications, lipid-rich necrotic core, intraplaque hemorrhage, thin or ruptured fibrous cap, plaque ulceration, degree of stenosis, plaque size or plaque inflammation. Studies using ultrasonography were excluded.

    Compared with women, men had larger plaques and plaques with calcifications more often (odds ratio [OR]=1.57; 95% confidence interval [CI]=1.23–2.02) as well as lipid-rich necrotic core (OR=1.87, 95% CI=1.36–2.57), and intraplaque hemorrhage (OR=2.52, 95% CI=1.74–3.66) or an ulcerated plaque (OR=1.81, 95% CI=1.30–2.51). Symptomatic participants demonstrated more sex differences for lipid-rich necrotic core than asymptomatic participants.

    No sex differences were found in the normalized wall index. All three measures of plaque size (one-, two- and three-dimensional) were sex-dependent, with men having larger plaque sizes. Some mechanisms have been proposed to underly the differences between men and women in carotid atherosclerosis, such as sex hormones, systemic inflammation and genetics. The gut microbiome has also been a focus of study for prevention of cardiovascular disease, and may play its role as a mediator in the development of carotid atherosclerosis, the authors wrote.

    The investigators concluded that sex is an important variable to consider in clinical and research settings. Every type of plaque feature — including lipid-rich necrotic core, intraplaque hemorrhage and calcification—was more common in men compared with women. They noted that future studies should focus on sex-specific stroke risks and review plaque composition.


    van Dam-Nolen DHK, van Egmond NCM, Koudstall PJ, et al. Sex Differences in Carotid Atherosclerosis: A Systematic Review and Meta-Analysis. Stroke 2023 Jan 23. (Article in press)

    Image Credit: songkram –

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