Sex Differences in Atherosclerotic Coronary Artery Disease Patterns

Background: Sex differences in coronary artery disease (CAD) have been increasingly recognized, as women present with distinct clinical characteristics and outcomes compared with men. This study investigated the impact of sex on pathophysiological CAD patterns (focal versus diffuse) in stable patients undergoing percutaneous coronary interventions (PCI). Methods: We conducted a subanalysis of the PPG Global (Pullback Pressure Gradient Global Registry) study, a multicenter, prospective trial including 993 patients (236 [23.8%] women and 757 [76.2%] men) with hemodynamically significant CAD, defined as fractional flow reserve ≤0.80. The pullback pressure gradient metric categorized CAD patterns as focal or diffuse. Patient-reported outcomes were collected using the 7-item Seattle Angina Questionnaire. Optimal revascularization was defined as post-PCI fractional flow reserve ≥0.88. Results: Women were significantly older than men, with a mean age of 69.8±10.3 years compared with 67.0±10.1 years (P<0.001). Despite similar baseline fractional flow reserve (0.69±0.12 versus 0.67±0.11, P=0.093), women reported more severe symptoms compared with men, as reflected in the Seattle Angina Questionnaire-7 angina frequency score (mean 76.7±22.9 versus 81.5±20.3, P=0.002). Women exhibited a more focal CAD pattern (pullback pressure gradient 0.65±0.16 versus 0.61±0.16, P=0.001) and achieved higher post-PCI fractional flow reserve values (0.88±0.07 versus 0.87±0.07, P=0.02). Women undergoing PCI had a higher rate of optimal revascularization (54% versus 44%, P=0.01). Conclusions: This study reveals clinically significant differences in CAD patterns between sexes, with women demonstrating a higher burden of angina, more focal disease distribution, and better physiological results after PCI. Keywords: Seattle Angina Questionnaire; coronary artery disease; fractional flow reserve; pullback pressure gradient; sex differences.