Gender Based Comparison of Clinical Presentation, Diagnosis, Treatment of Coronary Artery Disease and Risk Stratification using Global Registry of Acute Coronary Events Risk Score

Cardiovascular diseases (CVDs) are a group of conditions affecting the heart and blood arteries ^[1]. The Crude CV Mortality is expected to be rapidly rise by 73.4% demonstrating that the Ageing global populace will be an important driver of the CV burden ^[2]. Coronary artery disease (CAD) is a common cardiac illness that causes the major blood channels to constrict or get blocked. Plaque which is defined as a fatty substance formed by LDL Cholesterol deposition inside the intima, luminal narrowing that leads to myocardial ischemia which is the main cause of CAD ^[3].  

Women frequently experience atypical symptoms of CAD, such as fatigue, dyspnea, dyspnea on exertion, sweating, epigastric pain and nausea, whereas men usually exhibit "classic" symptoms, such as chest discomfort, radiating pain. Stress and emotional variables could affect women with CAD more profoundly, perhaps initiating symptoms ^[4,5]. Evaluation of CAD in women is further restricted by lower accuracy of electrocardiographic response to exercise stress tests in women compared within men ^[6]. In women who are more likely to present with nonobstructive CAD, a condition that has a worse prognosis even though it is frequently written off as not important, imaging modalities for stress testing may be less than ideal ^[7].Furthermore, despite having a greater load of comorbidities and worse outcomes than males, women are less likely to obtain guideline-directed medical therapy, according to observational data ^[8].       

The GRACE score incorporates eight independent prognostic variables including age, heart rate, systolic blood pressure, serum creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated cardiac biomarkers ^[9]. GRACE risk score is distinct in that it predicts both short-term outcomes like in-hospital mortality, as well as long-term outcomes that extend to six months or longer. This is advantageous in that it guides the clinician in both acute care and discharge planning ^[10]. The current study provides a comprehensive gender-based analysis of the disease by simultaneously examining the presentation of the disease, diagnostic results, treatment practices, and risk stratification using the GRACE risk score in a real-world scenario. Also previously, the GRACE score was calculated by the retrospective data of the patients but the present study includes the real-world population in the hospital to calculated the mortality risk in CAD patients.

MATERIALS AND METHODS:

The prospective observational study was conducted in the Department of cardiology Sudha Hospital Erode, after obtaining approval from the Institutional Ethics Committee (ECR/948/Inst/TN/2018/RR-22). A specially designed data collection form was used to record patient demographics and drug therapy details. Patients who came to the hospital during the study period with coronary artery disease as diagnosis and satisfying all the inclusion criteria were selected for the study then Data from male and female patients were compared to evaluate differences in clinical presentation, diagnosis, treatment patterns and analyzed the probability of 6 months mortality risk using GRACE risk score.

Study Criteria:

Inclusion Criteria:

• Patients who are diagnosed with coronary artery disease based on Clinical presentation, ECG and Angiographic findings.
• Patients aged >18 years.
• Patients admitted for medical management or interventional procedures.
• Patients willing to participate and provide written informed consent.

Exclusion Criteria:

• Pregnant and lactating women with coronary artery disease
• Patients with severe psychiatric illness with CAD symptoms
• Patients discharged against medical advice before evaluation completion.      

Statistical Analysis:

Statistical analysis was performed using SPSS software. The Chi-Square test was applied to evaluate gender-based differences in clinical presentation, diagnosis, treatment patterns and six-month mortality risk as assessed by the GRACE risk score with a significance threshold of p<0.05. The chi- square goodness of fit test was utilized to identify the risk factor associated in male and female related to social history in males and menopausal status in females.

RESULTS

Table 1: Patient Demographics and Comorbidity Profile

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value	p-value
Age groups
21-40	15	8.57	7	4	9.634	0.021
41-60	100	57.14	82	46.86
61-80	56	32.00	78	44.57
81-100	4	2.29	8	4.57
BMI Category
Underweight	2	1.14	5	2.86	12.605	0.005
Normal	68	38.86	40	22.86
Overweight	93	53.14	108	61.71
Obese	12	6.86	22	12.57
Co-morbid Conditions
Diabetes Mellitus	26	14.86	27	15.43	12.787	0.4643
Hypertension	19	10.86	21	12
CAD	12	6.86	12	6.86
Thyroid	1	0.57	2	1.14
Angina	0	0	1	0.57
Bronchial asthma	0	0	1	0.57
COPD	1	0.57	1	0.57
Ca gall bladder	0	0	1	0.57
Dyslipidemia	0	0	1	0.57
CVA	1	0.57	0	0
Psoriasis	1	0.57	0	0
Ischemic heart disease	1	0.57	0	0
More than 2 diseases	65	37.14	143	44.57
Nil	48	27.43	78	17.14

Table 2: Medical, Family and Social History of Patients

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value	p-value
Past medication history
Disease on treatment	82	46.86	91	52	5.440	0.065
Disease on irregular treatment	45	25.71	54	30.86
Not on treatment	48	27.43	30	17.14
Family history
Father-DM	1	0.57	1	0.57	9.026	0.2507
Father-HTN	0	0	1	0.57
Father-MI	0	0	3	1.71
Father-CAD	0	0	1	0.57
Mother-CAD, DM	1	0.57	0	0
Sibling-CAD	2	1.14	0	0
Sibling-MI	0	0	1	0.57
Nil	171	97.71	168	96
Social history
Alcoholic but not smoker	19	10.86	0	0	105.39	<0.001
Smoker but not alcoholic	38	22.29	0	0
Smoking & Alcoholic	23	13.14	0	0
Neither Alcoholic nor smoker	94	53.71	175	100

 

Table 3: Menopausal Status and Clinical Presentation

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value	p-value
Menopausal status
Menopaused	-	-	129	73.71	147.39	<0.001
Premenopausal	-	-	46	26.29
Nil	-	-	0	0
Clinical Presentations
Typical symptoms	30	17.14	23	13.14	10.048	0.0065
Atypical symptoms	16	9.14	37	21.14
Typical and Atypical symptoms	129	73.71	115	65.71

 

 

 

Figure 1: Clinical presentation experienced by the patients

Table 4: Distribution of Hypertension Stages

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value	p-value
Hypertension Stages
<120mmHg (Normal)	34	19.43	51	29.14	17.279	0.001
120-129 mmHg (Elevated)	48	27.43	21	12
130-139 mmHg (Hypertension stage 1)	43	24.57	37	21.14
≥140 mmHg (Hypertension stage 2)	45	25.71	56	32
≥180 mmHg (Hypertensive crisis)	5	2.86	10	5.71

 

Table 5: Lipid Parameters

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value	p-value
Serum total cholesterol level
<200 mg/dl (Normal)	123	70.29	97	55.43	8.9121	0.011
200-239 mg/dl (Borderline high)	35	20	47	26.86
≥240 mg/dl (High)	17	9.71	31	17.71
Serum HDL cholesterol level
<40 mg/dl (men) & <50 mg/dl (women) -optimal	114	65.14	143	81.71	23.531	<0.001
40-60mg/dl (men) & 50-60mg/dl (women) – borderline high	59	33.71	23	13.14
>60mg/dl (both) – high	2	1.14	9	5.14
Serum LDL cholesterol level
<100mg/dl (optimal)	61	34.86	55	31.43	2.5321	0.638
100-129mg/dl (near or above optimal)	56	32	56	32
130-159mg/dl (borderline high)	39	22.29	43	24.57
160-189mg/dl (high)	14	8	11	6.29
≥190mg/dl (very high)	5	2.86	10	5.71
Serum Triglycerides level
<150 mg/dl (Normal)	104	59.43	72	41.14	12.928	0.004
150-199 mg/dl (Border line high)	22	12.57	40	22.86
200-499 mg/dl (High)	46	26.29	58	33.14
≥500mg/dl (Very high)	3	1.71	5	2.86

 

Table 6: Electrocardiographic Findings

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value	p-value
ECG patterns
ST segment elevation	54	30.86	36	20.57	10.334	0.035
ST segment depression	22	12.57	35	20
Abnormal T waves/ inverted T wave	15	8.57	8	4.57
ST segment deviation + T wave abnormality	5	2.86	3	1.71
No ST segment deviation	79	45.14	93	51.14

Table 7: Coronary Vessel Involvement and Interventional Procedures

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value		p-value
Type of vessel disease
Single vessel disease	95	54.29	79	45.14	11.731	0.038
Double vessel disease	35	20	42	24
Triple vessel disease	30	17.14	22	12.57
Single vessel disease + Intermediate/ branch disease	4	2.29	3	1.71
Minimal CAD	6	3.43	18	10.29
Normal coronaries	5	2.86	11	6.29
Type of vessel involved
LAD	66	37.71	58	33.14	14.297	0.046
LCX	9	5.14	6	3.43
RCA	19	10.86	12	6.86
LMCA	0	0	1	0.57
Ramus	1	0.57	0	0
More than 2 vessels	39	22.29	46	26.29
More than 3 vessels	30	17.14	23	13.14
Nil	11	6.29	29	16.57
Procedure done
PTCA	121	69.14	89	50.86	14.857	0.005
CABG	26	14.86	36	20.57
Medical management	27	15.43	49	28
AVR+ CABG	0	0	1	0.57
PTCA + CABG	1	0.57	0	0

Table 8: Treatment Modalities Classification

Variables	No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value		p-value
Treatment Pattern
Antiplatelets	168	96	161	92	15.926	0.0684
Anticoagulants	87	49.71	84	48
Statins	151	86.28	158	90.28
Beta blockers	114	65.14	108	61.71
ACE inhibitors	62	35.42	61	34.85
ARBs	16	9.14	30	17.14
Nitrates	15	8.57	10	5.71
Calcium Channel blockers	16	9.14	34	19.42
Antianginal drugs	34	19.42	20	11.42
Diuretics	77	44	75	42.85

 

 

Figure 2: Comparison of treatment pattern between male and female coronary artery disease patients

 

Table 9: Prognostic Risk Assessment using GRACE Score

Variables		No. of male patients (n=175)	Percentage (%)	No. of female patients (n=175)	Percentage (%)	Chi square value		p-value
GRACE score
≤ 88 (Low risk)	103		58.86	77	44	10.322	0.005
89-118 (Intermediate risk)	56		32	65	37.14
≥ 119 (High risk)	16		9.14	33	18.86
Probability of death
< 3% (Low)	103		58.86	77	44	13.876	0.003
3-8% (Intermediate)	63		36	71	40.57
9-20% (High)	6		3.43	22	12.57
>20-40% (Very high)	3		1.71	5	2.86

 

 

 

Figure 3: Gender-wise distribution of patients according to GRACE score categories

 

 

Figure 4: Gender-wise distribution of estimated probability of death from admission to 6 months based on GRACE risk stratification

DISCUSSSION

Coronary artery disease (CAD) is one of the leading causes of morbidity & mortality worldwide. In recent years, researchers have increasingly focused on how CAD differs between males and females in terms of risk factors, clinical presentation, diagnosis, treatment, and outcomes. These differences may be due to several factors, including hormonal influences, variations in cardiovascular risk profiles, and lifestyle or behavioral factors. Tools such as the GRACE (Global Registry of Acute Coronary Events) risk score are commonly used to estimate mortality risk and assist clinicians in making appropriate treatment decisions for patients with acute coronary syndromes.

CAD occurs earlier in men (41–60 years) and later in women (61–80 years), showing a significant age difference (p = 0.021). This delayed onset in women may be due to estrogen’s cardioprotective effects, consistent with findings by Sayed et al., (2022). BMI distribution differed significantly between sexes (p = 0.005), with females showing higher rates of overweight and obesity compared to males. Similar findings by Won-Jang Kim et al., (2024) reported higher BMI and associated hypertension in women, increasing cardiovascular risk. Co-morbid conditions showed no significant difference between sexes (p = 0.464), with diabetes and hypertension being most common in both groups. Similar findings by Dronker et al., (2022) also reported no significant sex-based differences despite slight variations in risk patterns

Past medication history showed no significant difference between sexes (p = 0.065), although females demonstrated slightly better treatment adherence. This contrasts with findings by Hend Mansoor et al., (2024), which reported higher nonadherence among women, increasing cardiovascular risk. Familial risk factors showed no significant difference between sexes (p = 0.2507), with most patients lacking a documented family history of CAD. This contrasts with Bagheri et al., (2025), which reported a strong association between family history and CAD severity (p < 0.001). Social risk factors showed a highly significant difference between sexes (p < 0.001), with smoking and alcohol use reported only among men. Similar findings by Taqiuddin et al., (2024) identified smoking as a strong risk factor for CAD (OR = 2.80).

Menopausal status showed a highly significant association with CAD (p < 0.001), with most female patients being postmenopausal. Similar findings by Ayesha Siddika et al., (2023) reported greater CAD severity in postmenopausal women. Clinical presentation differed significantly between sexes (p = 0.0065), with females more likely to present with atypical symptoms. Similar findings by Simran P. Sharma et al., (2022) reported more classical chest pain in men and atypical symptoms in women

Hypertension stages showed a significant gender difference (p = 0.001), with elevated BP more common in men, while severe stages were higher in females. Similar findings by Min-Sik Kim et al., (2022) reported increased BP in postmenopausal women, emphasizing the need for control.

Significant gender differences were observed in lipid profiles, with females showing higher total cholesterol (p = 0.011), lower HDL (p < 0.001), and higher triglycerides (p = 0.004), while LDL levels showed no significant difference (p = 0.638). Similar findings by Rashid Mir et al., (2022) support these variations in lipid patterns between genders

ECG abnormalities showed a significant gender difference (p = 0.035), with ST-segment elevation more common in males and ST-segment depression more frequent in females. Similar findings by Al-khlaiwi et al., (2025) also reported sex-based differences in ST-segment patterns

Angiographic patterns showed a significant gender difference (p = 0.038), with males having more single and triple vessel disease, while females more often had minimal or normal coronary findings. Similar results by Kim et al., (2022) reported higher obstructive CAD in males. Coronary vessel involvement showed a significant gender difference (p = 0.046), with LAD most commonly affected in both sexes; males had higher RCA and LCX involvement, while females showed more multivessel disease. These findings partly contrast with Al-khlaiwi et al., (2025), which reported no significant gender difference in LAD involvement. Revascularization strategies showed a significant gender difference (p = 0.005), with males more likely to undergo PTCA and females more often receiving CABG or conservative management. Similar findings by Wester et al., (2024) reported higher CABG rates in women and more graft use in men

Pharmacological treatment patterns showed no significant gender difference (p = 0.0684), with antiplatelets and statins commonly used in both sexes. This contrasts with Alhassan et al., (2025), which reported lower use of guideline-recommended therapies in women.

GRACE score distribution and estimated 6-month mortality risk showed significant gender differences (p = 0.005, p = 0.003), with females more often in intermediate and high-risk categories. Similar findings by Wenzl et al., (2022) reported higher mortality risk in women

CONCLUSION

This study demonstrates that significant gender differences exist in coronary artery disease (CAD). Males are more likely to develop CAD at a younger age with higher exposure to lifestyle risk factors, whereas females tend to present later in life with more metabolic risk factors and atypical symptoms. These differences may lead to delays in diagnosis in female patients. Additionally, females showed higher GRACE risk scores, indicating a greater risk of mortality and poorer prognosis compared to males. Overall, gender plays an important role in the clinical presentation, risk assessment, and outcomes of CAD. Therefore, early detection, gender-specific risk assessment, and appropriate management strategies are essential to improve outcomes, especially in female patients.

CONFLIT OF INTEREST: None

ACKNOWLEDGMENT:

I would like to express my sincere gratitude to Dr.N.Rajasekar,MD (Cardiologist) from the Cardiology department for his invaluable support and gratitude throughout this project. His expertise and encouragement have been instrumental in shaping our research.

ABBREVATIONS:CAD: Coronary Artery Disease; GRACE: Global Registry of Acute Coronary Events Risk Score; ECG: Electro Cardiogram; CAD: Cardiovascular Disease; CV: Cardiovascular; FAST-MI: French registry of Acute ST-elevation and non -ST-elevation Myocardial Infraction; BMI: Body Mass Index; COPD: Chronic Obstructive Pulmonary Disease; CVA: Cerebro Vascular Attack; DM: Diabetes Mellitus; MI: Myocardial Infraction; HTN: Hypertension; HDL: High Density Lipoprotein; LDL: Low Density Lipoprotein; LAD: Left Anterior Descending Artery; LCX: Left Circumflex Artery; LMCA: Left Main Coronary Artery; PTCA: Percutaneous Transluminal Coronary Angioplasty; CABG: Coronary Artery Bypass Graft; AVR: Aortic Valve Replacement

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