Recent Advances in Cardiology
Effect of menopause on plaque morphologic characteristics in coronary atherosclerosis,☆☆,

https://doi.org/10.1067/mhj.2001.109946Get rights and content

Abstract

Background Coronary artery disease in women appears 10 to 15 years later than in men. To test the hypothesis that the effects of estrogen may manifest themselves as histologic differences in coronary plaques, we examined the hearts of premenopausal and postmenopausal women who died suddenly from coronary artery disease. Methods We studied 51 cases of sudden coronary death and 47 deaths in women who died from noncoronary causes. Coronary deaths were classified on the basis of histologic features. The number of acute plaque ruptures, healed plaque ruptures, vulnerable plaques, and acute plaque erosions were compared between groups. Postmortem values of serum total cholesterol, HDL cholesterol, and thiocyanate were measured, and menopausal status was confirmed by calculating body mass index. Results Women older than 50 years of age were much more likely to have a ruptured plaque than were younger, premenopausal women. Plaque rupture was significantly associated with elevated total cholesterol level. In the 51 women who died of coronary disease, the mean number of vulnerable plaques increased significantly as women advanced into the postmenopausal years. Conclusions Our data suggest that estrogen has an anti-inflammatory effect on atherosclerotic plaques, resulting in plaque stabilization. Plaque erosion, the major substrate for thrombosis in premenopausal women, does not appear to be inhibited by estrogen. Because plaque progression may result both from repeated rupture and repeated erosion, a better understanding of the effect of estrogen on atherosclerosis may yield insights into the nature of coronary artery disease. (Am Heart J 2001;141:S58-62.)

Section snippets

Case selection

Women who died suddenly were evaluated prospectively in consultation, as previously reported.13 This study included 51 previously reported cases of sudden coronary death (Table I)13 and 47 deaths (control group) in women who died from noncoronary causes studied during the same period (Table II). In addition, nonculprit coronary plaque morphologic characteristics were compared between women <50 years and women >50 years.

Examination of the heart and determination of type of death

Hearts were perfusion-fixed in buffered formalin, and epicardial arteries

Correlation of risk factors with culprit plaque morphologic characteristics

This dataset was composed of 51 women who died suddenly with acute coronary artery disease and 47 control subjects. Women older than 50 years were much more likely to have a ruptured plaque than were younger, premenopausal women (Table I). Plaque rupture was associated with elevated total cholesterol, body mass index, and elevated glycosylated hemoglobin by univariate analysis (Table I). Plaque erosions, which occurred most frequently in premenopausal women, were associated with cigarette

Discussion

We have demonstrated significant differences in the plaque morphologic characteristics of premenopausal women versus older women who died suddenly from coronary artery disease. The culprit plaque in premenopausal women rarely appeared ruptured; in those few young women with plaque rupture, serum total cholesterol level was severely elevated. Because the major cause of coronary thrombosis in men and postmenopausal women is plaque rupture, the protective effects of estrogen may lie largely in its

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Supported in part by research grant RO1HL61799-02 from the National Institutes of Health.

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The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army, the Department of the Air Force, or the Department of Defense.

Reprint requests: Renu Virmani, MD, Department of Cardiovascular Pathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000. E-mail: [email protected]

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