Effect of risk factors on the mechanism of acute thrombosis and sudden coronary death in women

Background-Traditional risk factors have been linked to atherosclerotic heart disease in women. However, the effect of risk factors and menopausal status on the mechanism of sudden coronary death is unknown. Methods and Results-We examined 51 cases of sudden coronary death and 15 hearts from women who died of trauma. Coronary deaths were divided into four mechanisms of death: ruptured plaque with acute thrombus (n=8), eroded plaque with acute thrombus (n=18). stable plaque with healed infarct (n=18), and stable plaque without infarction (n=7). Vulnerable plaques prone to rupture were defined as those with a thin, fibrous cap infiltrated by macrophages and were quantitated in coronary deaths and control subjects. Total cholesterol (TC), HDL cholesterol, glycosylated hemoglobin, cigarette smoking, and hypertension were determined in each case. Compared with control subjects, women with plaque ruptures had elevated TC (270+/-55 versus 194+/-44 mg/dL, P=0.002), and those with erosions were more likely to be smokers (78% versus 33%, P=0.01). Women with stable plaque and healed infarct had elevated glycosylated hemoglobin (10.2+/-5.0% versus 6.4+/-0.4% in control subjects, P=0.001) and were more likely to be hypertensive (50% versus 15% in control subjects, P=0.03), By multivariate analysis, cigarette smoking was associated with plaque erosion (P=0.03, odds ratio [OR] 21), glycoslyated hemoglobin with stable plaque and healed infarct (P=0.03, OR 41), TC with plaque rupture (P=0.02, OR 7), and hypertension with stable plaque with healed infarct (P=0.02, OR 15). Seven of 8 plaque ruptures occurred in women >50 years of age versus 3 of 18 erosions (P=0.001). In cases of coronary death, vulnerable plaques were associated with elevated cholesterol (P=0.002) and age >50 years (P=0.002), independent of other risk factors. Conclusions-In women, traditional risk factors have distinct effects on the mechanisms of sudden coronary death, which vary by menopausal status. Effective risk factor modification may therefore differ between younger and older women and may be targeting different mechanisms of plaque instability.