European Journal of Cardiovascular Medicine

Cardiovascular diseases have emerged as a significant health burden and became leading cause of mortality in developing countries like India [1]. The Global Burden of Disease study and age-standardized estimates in India showed nearly a quarter (24.8%) of all deaths in India are attributable to cardio vascular Disease (CVD) out of which coronary artery disease (CAD) is the leading cause of mortality and morbidity[2]. Women have greater CVD mortality and report more disability and decreased quality of life. Throughout the 20 th century CAD was viewed predominantly as problem of middle-aged men and little information was available regarding its impact on women. With emerging research studies specific to women now exists burgeoning evidence based on gender differences in presentation, diagnosis management and clinical outcomes in women as compared with men in regard to suspected or diagnosed cases of CAD [3]. The worldwide INTERHEART Study [4], done in 52000 individuals with myocardial infarction, have revealed that women have their first presentation of coronary heart disease approximately 10 years later than men, most commonly after menopause, but have poorer prognosis and more severe outcome than men3. The overall short term and long-term mortality following a Myocardial Infarction in CAD are about 40% higher in women after adjustment for age and other risk factors. In comparison with men, tend to have a better risk factor profile at younger ages, whereas the opposite is true at older ages [5]. Due to lower prevalence of anatomical coronary obstructive disease even with greater myocardial ischemia and associated mortality when compared to men due to existing sex differences such as genetic, hormonal and increasingly acknowledged to exist at cellular levels.Epidemiological studies from India reported that there is definite rising trends and a high burden in the levels of conventional risk factors such as DM, HTN and metabolic syndrome, tobacco usage, Obesity in women. Among Indian women, the presence of HTN, DM, low levels of HDL and high Total cholesterol levels, High triglycerides, High LDL levels are correlated with coronary artery disease [6].  Apart from traditional Risk factors women have specific risk factors unique during her life time including pregnancy related Adverse pregnancy outcomes and post-menopausal women tend to present with atypical symptoms thus delay in initiation of treatment. From 1960 to 1995, the prevalence of CAD in women increased from 3% to 10% in urban Indians and from 2% to 4% in rural Indians and women having incidence rates similar to men. 

The aim of this study is to evaluate the clinical and angiographic profile of women presenting with coronary artery disease (CAD) at a tertiary cardiac care center. The objectives include assessing the demographic and socioeconomic characteristics, as well as identifying major risk factors such as hypertension, diabetes, dyslipidaemia, smoking, and family history. Additionally, the study seeks to analyse the etiological spectrum and angiographic patterns, including the number and distribution of affected coronary vessels. A comparative analysis will also be conducted to correlate specific risk factors with clinical presentations and angiographic patterns of CAD, thereby providing insights into gender-specific manifestations and potential disparities in diagnosis and management.

Study Design: Single-centre, prospective study conducted in the Department of Cardiology, King George Hospital, Visakhapatnam

Study Population:The study included 707 patients presented to the department of cardiology, KGH, between December 2021 and June 2023 with a diagnosis of CAD and who underwent Coronary angiography.

Inclusion Criteria: Female patients above 18 years admitted with diagnosis of coronary artery disease in Department of cardiology, King George Hospital and willing to give written consent and participate in study.

Exclusion Criteria:

1. Patients not willing to give consent
2. Patients with known valvular heart surgery
3. Patients with chronic kidney disease
4. Patients with age below 18 years
5. Patients In whom CAG was not be done – not willing or contraindications to CAG

Statistical Analysis: -

For statistical analysis, data were initially entered into a Microsoft Excel spread sheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and Graph Pad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analyzed using SPSS and Graph Pad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Showing Baseline Characteristics in study population.

Table 2: Showing Distribution of Various Risk factors in study population

Table 3: Showing Distribution of Various Risk factors in study population

Table 4: Showing distribution of Biochemical parameters

Table 5: showing distribution of CAD Diagnosis at the time of presentation

Table 6: Distribution of CAD Diagnosis at the time of presentation

Figure 1. Distribution of CAD pattern in young vs elderly women

 Figure2. CAD pattern in women with DM

Figure 3. CAD pattern to women with HTN

Figure 4. CAD pattern with Menopause

In the present study comprising 707 participants, the mean age was 55.42 ± 10.86 years, ranging from 24 to 88 years. The average height and weight were 151.25 ± 6.62 cm and 57.8 ± 11.75 kg, respectively, resulting in a mean BMI of 25.25 ± 4.95 kg/m². The mean hemoglobin level was 10.73 ± 1.10 g/dL. Regarding lipid profile, the mean total cholesterol (TC) was 189.38 ± 63.7 mg/dL, triglycerides (TG) averaged 124.2 ± 74.88 mg/dL, HDL cholesterol was 40.77 ± 8.3 mg/dL, and LDL cholesterol was 114.05 ± 52.62 mg/dL. The mean TC/HDL and TG/HDL ratios were 4.84 ± 1.97 and 3.21 ± 2.15, respectively. The average ejection fraction (EF) was 51.22 ± 10.17%. Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 130.7 ± 22 mmHg and 85.68 ± 60.63 mmHg, respectively. These findings provide a comprehensive overview of the demographic and clinical characteristics of the study population.

In this study cohort, the majority of women presenting with coronary artery disease were above 55 years of age (48.1%), followed by those aged 45–55 years (30.8%) and less than 45 years (21.1%). Regarding BMI distribution, nearly half of the participants (48.9%) had a normal BMI (18.5–25), while 31.5% were overweight (25–30), 15.1% were obese (>30), and 4.4% were underweight (<18.5). Tobacco use was reported in 7.9% of the women, whereas 92.1% did not consume tobacco. Diabetes mellitus was present in 41.7% of patients, and hypertension in 60.3%. A large proportion (92.5%) were postmenopausal. A positive family history of coronary artery disease was observed in 3.8% of participants. Additionally, metabolic syndrome was identified in 5.8% of the women.

Among the women studied, the majority had mild anaemia (64.5%), while 18.7% had moderate anaemia, 1.1% had severe anaemia, and only 15.7% had normal haemoglobin levels. Regarding lipid profile, 41.6% had elevated total cholesterol (>200 mg/dl), whereas 58.4% had normal levels (<200 mg/dl). Elevated triglyceride levels (>150 mg/dl) were found in 31.1% of participants, with the remaining 68.7% within the optimal range. Low HDL cholesterol (<50 mg/dl) was observed in 87.7% of patients, and only 12.3% had optimal HDL (>50 mg/dl). High LDL cholesterol (>100 mg/dl) was present in 53.3%, while 46.7% had optimal levels (<100 mg/dl). The TC/HDL ratio was at risk (>5) in 37.2% and optimal (<5) in 62.8% of women. Similarly, the TG/HDL ratio was at risk (>3.8) in 31.5% of cases and optimal in 68.5%.

In terms of clinical presentation, the most common diagnosis among women was STEMI, observed in 46.1% of patients, followed by unstable angina in 29.8%, and chronic stable angina (CSA) in 7.9%. Typical chest pain without documented ischemia was seen in 9.2% of cases, while atypical chest pain accounted for 3.4%. Additionally, NSTEMI was diagnosed in 3.5% of the study population.

Angiographic analysis revealed that obstructive coronary artery disease (CAD) was significantly more common in women older than 55 years (62.6%) compared to those ≤55 years (37.4%; p < 0.001). Similarly, patients aged over 45 years showed a higher prevalence of obstructive CAD (90.2%) compared to those ≤45 years (9.8%; p < 0.001). BMI was also significantly associated: patients with BMI 18.5–25 and BMI <30 had a higher proportion of obstructive CAD (55.6% and 88.8%, respectively; p < 0.001).

Diabetes was significantly associated with obstructive CAD, being present in 49.8% of these patients versus 29.2% with non-obstructive CAD (p < 0.001). Hypertension and menopause were also significantly more prevalent among women with obstructive CAD (66.3% and 80.9%, respectively) compared to those with non-obstructive disease (50.9% and 61.4%; both p < 0.001).

No statistically significant association was observed between angiographic outcome and tobacco use (p = 0.09), family history of CAD (p = 0.066), or metabolic syndrome (p = 0.523).

Haemoglobin status showed a significant association with angiographic outcomes (p < 0.001). Moderate anaemia (21.6%) and mild anaemia (67%) were more common among women with obstructive CAD, while normal haemoglobin was more frequent in those with non-obstructive disease (24.2% vs. 10.2%).

Dyslipidemia also demonstrated significant associations. High total cholesterol (>200 mg/dl) was present in 56.7% of women with obstructive CAD compared to 18.1% in the non-obstructive group (p < 0.001). Similarly, high triglycerides (>150 mg/dl) were seen in 44.2% of patients with obstructive CAD versus 10.8% in those with non-obstructive disease (p < 0.001). High LDL (>100 mg/dl) was significantly more prevalent among obstructive CAD patients (68.8% vs. 29.2%; p < 0.001).

For HDL cholesterol, although low HDL (<50 mg/dl) was common in both groups, optimal HDL (>50 mg/dl) was more frequent in the obstructive CAD group (14.7% vs. 8.7%; p = 0.018). The TC/HDL ratio and TG/HDL ratio were also significantly higher among women with obstructive CAD: at-risk TC/HDL ratio (>5) in 48.6% versus 19.5% (p < 0.001) and at-risk TG/HDL ratio (>3.8) in 43.5% versus 13.0% (p < 0.001).

In the present study of 707 women presenting with coronary artery disease (CAD), several demographic, metabolic, and angiographic patterns emerged, largely aligning with previously published literature. The mean age of the cohort was approximately 55 years, and the majority of women with obstructive CAD were older than 55 years (62.6%), underscoring age as a significant risk factor. This finding is consistent with the work by Mosca et al. (2011), which highlighted that increasing age remains a dominant non-modifiable risk factor in women [7].

Regarding metabolic risk factors, diabetes and hypertension were significantly associated with obstructive CAD in our study, being present in 49.8% and 66.3% respectively—higher than in women with non-obstructive disease. Similar trends have been observed by Shaw et al. (2006) in the Women’s Ischemia Syndrome Evaluation (WISE) study, which reported diabetes and hypertension as key predictors of obstructive CAD in women [8]. Importantly, the prevalence of postmenopausal status was notably high (92.5%), and menopause was more common in those with obstructive CAD, echoing evidence by Shaw LJ (2009), who described menopause as an accelerator of atherosclerotic risk [9].

Dyslipidemia also played a crucial role. Elevated total cholesterol, triglycerides, LDL cholesterol, and higher TC/HDL and TG/HDL ratios were significantly associated with obstructive CAD. This pattern mirrors findings from Karalis et al. (2007), who documented the strong association between elevated LDL and low HDL with angiographically proven CAD in women [10]. Notably, low HDL was common across both groups, but optimal HDL was paradoxically slightly higher in the obstructive group (14.7% vs. 8.7%), which could reflect the complexity of lipid interactions or residual confounding.

Anaemia was another significant predictor, with moderate and mild anaemia more frequent among those with obstructive CAD (p < 0.001). This supports the observation by Anand et al. (2004), who reported that anaemia independently increases CAD risk and is associated with worse angiographic severity and prognosis [11]. Conversely, lifestyle factors such as tobacco use and family history did not show significant associations in our cohort, which contrasts with some prior studies where tobacco was a stronger predictor, suggesting possible regional or cultural differences in smoking prevalence among women.

Overall, our study reinforces the interplay of traditional risk factors—particularly age, diabetes, hypertension, dyslipidemia, menopause, and anaemia—in predicting obstructive CAD in women. Compared to earlier large cohorts and registry studies, our findings highlight a similar risk profile but with locally relevant nuances such as higher prevalence of anaemia and postmenopausal status, which may guide tailored prevention and intervention strategies in this population.

We conclude that, this study highlights that among women presenting with coronary artery disease, older age, higher BMI, diabetes, hypertension, and postmenopausal status were significantly associated with obstructive CAD. Anaemia and dyslipidaemia—particularly elevated total cholesterol, triglycerides, LDL cholesterol, and adverse TC/HDL and TG/HDL ratios—were also more prevalent among those with obstructive CAD. Conversely, factors such as tobacco use, family history, and metabolic syndrome did not show significant associations with angiographic outcomes. Overall, the findings underscore the important role of age-related, metabolic, and hematological factors in influencing the severity and pattern of coronary artery disease in women.

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