Nigerian Journal of Cardiology

: 2018  |  Volume : 15  |  Issue : 1  |  Page : 20--27

Detection of extension and distribution diversity of coronary artery diseases by gender using Syntax score I

Yalcin Boduroglu1, Nazan Erenoglu Son2, Osman Son3,  
1 Department of Cardiology, Antalya Private Life Hospital, Antalya, Turkey
2 Department Nutrition and Dietetics, Afyon Kocatepe University, Afyon, Turkey
3 Department of Endocrinology, Private Acibadem Hospital, Eskisehir, Turkey

Correspondence Address:
Dr. Yalcin Boduroglu
Department of Cardiology, Antalya Private Life Hospital, Cumhuriyet Mah. 629.Sok No: 16, Muratpasa, Antalya


Background: Although the extension and distribution of coronary artery diseases by gender was found in a same pattern, some studies reported controversial results, so we aimed to investigate these differences. Materials and Methods: Our study included a total of 963 patients with 67% of men and 33% of women. Results: Baseline features were similar except diabetes mellitus and age which were higher in women (P = 0,004 and P < 0,001, respectively). There was a significant difference between groups (P = 0.031). Women had significantly more one-vessel left anterior descending (LAD) lesions (30.8% vs. 22.0%; P = 0.004). However, there were no differences for other locations (P > 0.05). When collecting all kind of lesions in a same cluster (including one-, two-, and three-vessel diseases totally), the left circumflex artery (LCx) cluster was found significantly more in men (55.7% vs. 48.7%, P = 0.043). There was no difference in segmental distribution of lesions (P = 0.473). Low Syntax score was found to be the best determinant for one-vessel LAD lesions (P < 0.001); in contrast, intermediary and high Syntax scores were found for LCx cluster (P < 0.001). Syntax score I was found to be a significant negative predictor for one-vessel LAD lesions (P < 0.001, OR: 0.857), and low-density lipoprotein (LDL) cholesterol and Syntax score I and HbA1c were significant positive predictors for LCx cluster (P = 0.011, odds ratio [OR]: 1.011; P < 0.001, OR : 1,10; P = 0,015, OR: 1,22, respectively). Conclusions: We found one-vessel LAD lesions to be significantly more in women and LCx cluster in men. Syntax score I was found to be a negative predictor for one-vessel LAD lesions, but Syntax score I, LDL cholesterol, and HbA1c were positive predictors for LCx cluster.

How to cite this article:
Boduroglu Y, Son NE, Son O. Detection of extension and distribution diversity of coronary artery diseases by gender using Syntax score I.Nig J Cardiol 2018;15:20-27

How to cite this URL:
Boduroglu Y, Son NE, Son O. Detection of extension and distribution diversity of coronary artery diseases by gender using Syntax score I. Nig J Cardiol [serial online] 2018 [cited 2019 Jul 16 ];15:20-27
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Full Text


Coronary artery disease (CAD) is one of the leading causes of death worldwide. Globally, the chance of developing CAD is 2.2 times greater in men than in women.[1],[2] In a study, males had significantly larger and more calcified plaques than females who had smaller and significantly less calcified lesions.[3] Another study showed that men demonstrated higher rates of CAD (21% vs. 12%, P < 0,001), calcified plaque (6% vs. 3%, P = 0.01), and noncalcified plaque (9% vs. 5%, P = 0.008).[4] When comparing plaque components, women had greater percentage of necrotic core volume (19.0 ± 12.7% vs. 16.8 ± 11.9%, P = 0.040) and higher incidence of thin-cap fibroatheroma (62% vs. 52%, P = 0.078).[5] In another study, women had a similar number of angiographic culprit (P = 0.53), but had fewer nonculprit lesions (P = 0.05) and fewer vessels with nonculprit lesions (P = 0.048) compared with men, but there was a similar plaque burden per lesion (55.6% vs. 55.3%; P = 0.35).[6] Similar to this, in some studies, they found no differences of extent and distribution of the stenotic lesions of coronary artery beds between women and men.[7],[8] In contrast, in a recent study, Mona et al. found that Chinese women were more likely to have left-main and three-vessel disease compared to their male counterparts (P = 0.004), but not in other ethnic groups.[9],[10] Hence, these studies showed controversial reports on gender differences for extension of CAD and we aimed to investigate these differences in extension and distribution of lesions by gender.

 Materials and Methods

This retrospective study was conducted in the Cardiology Clinic of Private Sakarya Hospital in Eskisehir Province of Turkey. The study period was from January 2012 to January 2013. Patients who have either stable CAD or acute coronary syndrome due to de novo lesions were included in this study.

History of diabetes mellitus (DM), systemic arterial hypertension (HT), and dyslipidemia was also investigated. HT was defined as systolic blood pressure (BP) >139 mmHg or diastolic BP >89 mmHg or history of treatment for HT. DM was defined as fasting blood glucose >126 mg/dl or 2-h postload blood glucose >200 mg/dl or history of treatment of diabetes. Dyslipidemia was defined as low-density lipoprotein (LDL) cholesterol ≥100 mg/dl, high-density lipoprotein cholesterol ≤40 mg/dl, and triglyceride levels ≥150 mg/dl. On angiography, significant disease was defined as stenosis of >50% in the involved coronary artery. Syntax score I was calculated according to literature based on the nature of lesions on left anterior descending (LAD) artery, left circumflex artery (LCx), and right coronary artery (RCA) territories.[11] This study was approved by the Ethics Committee of Afyon University Clinical Investigation.

Statistical analysis

Continuous variables were expressed as mean ± standard deviation and categorical variables were presented as frequencies. Continuous and categorical measures were compared with t-tests or 2 statistics, as appropriated. Univariable and multivariable logistic regression models were used to estimate differences of significant CAD by gender. From the models, an odds ratio (OR) and 95% confidence interval (CI) were calculated. P < 0.05 was considered statistically significant.


Baseline descriptive analysis

A total of 963 patients were included in our study with 318 women (33%) and 645 men (67%). Baseline features were similar in women except higher rates of DM and age (70.8% vs. 61.9%, P = 0.004; mean ages: 68.8 ± 9.92 vs. 64.47 ± 11.27 years, P < 0.001, respectively) [Table 1].{Table 1}

Localization of coronary artery lesions

Angiographic findings showed that there was a significant difference between women and men on CAD localizations (P = 0.031) [Table 2]. Women had significantly more predilection of having one-vessel LAD lesions (30.8% vs. 22.0%; P = 0.004). There were no differences between groups for other locations (for all P > 0.05). There was a trend of high prevalence of one-vessel disease (45% vs. 29% vs. 26.4%, respectively) globally. The most common encountered locations of lesions were one-vessel disease of LAD region (30.8%), followed by three-vessel diseases (22.6%) and two-vessel diseases of LAD and RCA regions (12.3%) in women contrarily to men who had three-vessel diseases (28.2%) followed by one-vessel LAD region (22.0%) and then two-vessel diseases of LAD and LCx regions (13.0%). When collecting all kind of lesions in a same cluster (one, two, and three-vessel diseases), it was found that only cluster of LCx lesions showed significant difference between men and women (55.7% vs. 48.7%, P = 0.043) [Table 3]. LAD vs. RCA clusters did not show any differences (P > 0.005). When focusing on the distribution of lesions specifically, that is, proximal, mid, and distal portion of vessels, there was no significant difference between groups (P = 0.473) [Table 4]. When considering the Syntax score I, there was no significant difference for mean score between groups (P = 0.065) [Table 5]. After dividing the patients into three groups according to their Syntax score I point as Group 1 (low category), Group 2 (intermediary category), and Group 3 (high category), we considered only two different results between groups which were one-vessel LAD lesions and the cluster of LCx lesions and compared the groups for further evaluations.{Table 2}{Table 3}{Table 4}{Table 5}

When considering globally, most of the patients were categorized under low Syntax score group (82%, 14%, and 4%, P < 0.001) and the patients with low Syntax score (Group 1) had a higher predilection for one-vessel LAD lesions (30% vs. 2.8% vs. 0%, respectively, P < 0.001) in contrast to the cluster of LCx lesions, which was found to be in higher Syntax score group (Group 3) (46.4% vs. 83.1% vs. 91.2%, respectively, P < 0.001) [Table 6].{Table 6}

When looking into woman group specifically, Group 1 was found to be the best determinant for one-vessel LAD lesions (P < 0.001) [Table 7]; however, Group 2 was found to be the best determinant for cluster of LCx lesions (P < 0.001) [Table 8].{Table 7}{Table 8}

When looking into the group of men, again Group 1 was found to be the best determinant for one-vessel LAD lesions (P < 0.001) [Table 9]; however here, Group 3 was found to be the best determinant for a cluster of LCx lesions (P < 0.001) [Table 10].{Table 9}{Table 10}

When making a comparision groups again to counterparts between women and men for one-vessel LAD lesions, there was a significant difference only in Group 1 (P = 0.003) [Table 11], and for cluster of LCx lesions, Groups 1 and 3 reached statistically significant level (P = 0.048) [Table 11].{Table 11}

Logistic regression analysis

Logistic model is shown in [Table 12] and [Table 13]. For one-vessel LAD lesions, only Syntax score I reached significance level but had negative effect over one-vessel LAD lesions (B = -0,15, OR: 0.85; P < 0.001); LDL cholesterol, Syntax score I, and HbA1c showed significantly positive effect to probability of having of LCx lesions cluster (OR: 1.0; 1.1; 1.2 respectively, P < 0.05 for all) [Table 13].{Table 12}{Table 13}


The China Peace-Retrospective AMI study conducted on 11,986 patients showed the similarity in the extent of CAD between women and men,[12] but in another cohort, significance of CAD was reported to be more in men than in women (P = 0.0001).[13] Similarly, in many studies, it has been shown that women tend to have a lower prevalence of obstructive CAD. In some studies, the location and burden of CAD and extent and location of atheroma plaques were found to be with a different pattern in women and men.[4],[5],[6] In our study, women had more lesions in only one-vessel LAD group compared to men (30.8% vs. 22.0%, P = 0.004). There were no differences for the other regions (P = nonsignificant). We found another interesting finding that there was a significant difference when considering all kinds of lesions in a cluster which included LCx vessel specifically which was seen significantly in men (women vs. men: 48.7% vs. 55.7%, P = 0.043). Till now, we did not encounter this kind of evaluation and finding in the literature. The Confirm registry reported by Joshua et al., which followed 5632 patients (36.5% female) over the course of 5 years, found that obstructive CAD detected by coronary tomographic angiography was less common in women than in men (P < 0.001 for all).[14] In a study conducted from Yohei et al. who analyzed 10,220 patients' data that men tended to have more bifurcation lesions (26.8% vs. 23.6% P = 0.003) and chronic totally occluded (CTO) lesions (6.8% vs. 4.3%; P < 0.001) than women. two-vessel, three–vessel, left-main and CTO lesions were similar between groups (P > 0.05).[15]

Along with these trials in BARI study, the extent of coronary disease is similar to men. Specifically, the prevalence of one-vessel and multi-vessel diseases was notably, contrast to us, not different between women and men. The incidence of double- and triple-vessel diseases and the total disease burden (number of total, proximal, and diffuse lesions and lesion morphology) were similar in women and men.[22]

Recently, a study conducted by Supriya et al. found that coronary angiographic profile did not show any differences in the location or extent of CAD for single- and multi-vessel diseases and insignifi cant or normal CAD by gender (P = 0.840, P = 0.295, and P = 0.059, respectively).[10] When lesions were examined according to distribution such as proximal, mid, and distal proportion, there was no difference (P > 0.005 for all).

Felipe et al. found the prevalence of bifurcation, total occlusion, small vessels, diffuse disease, left main, LAD, LCx, and RCA lesions to be significantly more frequent in the Syntax score high category (≥23) (P = 0.001 for all) in 895 patients. However, they did not categorize these lesions between women and men by sex.[16] These results are contrast to our findings maybe because in our study, most of the one-vessel LAD lesions were seen in low Syntax score category (Group 1) and LCX lesions in Groups 2–3. Giulio et al. found the same results in pooled 5011 individual patients' data. Women had a smaller reference target vessel diameter than men (P < 0.001) and had a smaller percentage stenosis of the target lesion (P = 0.02) and had a lower angiographic complexity as assessed by the Syntax score (P = 0.001). Their study showed a similar distribution of CAD (P = 0.62) but women tend to have more LAD lesions, fitting our results (42.0% vs. 39.9%; OR: 2.06), and men tend to have more LCx lesions, consistent with our results (24.4% vs. 23.3%; OR: 1.09).[17]

Contrast to us that all other big trials found higher rates of LAD lesions in high Syntax score groups but same with us for the LCx lesions. More complex and severe lesions were found common in upper tertile in earlier trials trials (P < 0.001 for all LAD and LCx lesions).[11],[18],[19],[20],[21] Following adjustment of the confounding factors' multivariate model, only Syntax score I remained an independent predictor of one-vessel LAD lesions (B − 0.15, OR: 0.85; 95% CI = 0.80–0.91; P < 0.001) and LDL cholesterol, Syntax score I, and HbA1c remained significant factors for a cluster of all kinds of LCx lesions (P < 0.05 for all).

Study limitations

In this study, we collected some clinical features of patients such as DM, LDL cholesterol, age, HT, and HbA1c. There are many predictor factors to affect CAD and these factors might be missing data in this study and might affect our results. There is a danger of overestimating the Syntax score if all ST-segment elevation myocardial infarctions with an occluded infarct-related vessels are taken as chronic total occlusions, particularly because the lesion is likely to be easier to treat due to the soft nature of plaque as opposed to an occlusion, which has calcified organized old thrombus and plaque (chronic occlusion). The limitation of the Syntax score I is that it does not incorporate clinical patient characteristics. This study may have limitations inherent to subgroup analysis (chance findings and underpowering). The relatively small sample size of the current study reiterates the need to validate the findings in a larger patient cohort.


In our retrospective angiographic analysis, we found that women tend to have more one-vessel LAD lesions, whereas men tend to have clusters of all kinds of lesions which included specifically LCX vessel. The current study needs to validate the findings in a larger patient cohort.


We wish to thank Mr. Ahmet Musmul from the Department of Medical Statistics, Afyon Kocatepe University, who helped to analyze statistical results of this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Allameh F, Pourmand G, Bozorgi A, Nekuie S, Namdari F. The association between androgenic hormone levels and the risk of developing coronary artery disease (CAD). Iran J Public Health 2016;45:14-9.
2Bairey Merz CN, Shaw LJ, Reis SE, Bittner V, Kelsey SF, Olson M, et al. Insights from the NHLBI-sponsored women's ischemia syndrome evaluation (WISE) study: Part II: Gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 2006;47:S21-9.
3Makaryus AN, Sison C, Kohansieh M, Makaryus JN. Implications of gender difference in coronary calcification as assessed by CT coronary angiography. Clin Med Insights Cardiol 2014;8:51-5.
4Otaki Y, Gransar H, Cheng VY, Dey D, Labounty T, Lin FY, et al. Gender differences in the prevalence, severity, and composition of coronary artery disease in the young: A study of 1635 individuals undergoing coronary CT angiography from the prospective, multinational confirm registry. Eur Heart J Cardiovasc Imaging 2015;16:490-9.
5Hong YJ, Jeong MH, Choi YH, Ma EH, Cho SH, Ko JS, et al. Gender differences in coronary plaque components in patients with acute coronary syndrome: Virtual histology-intravascular ultrasound analysis. J Cardiol 2010;56:211-9.
6Lansky AJ, Ng VG, Maehara A, Weisz G, Lerman A, Mintz GS, et al. Gender and the extent of coronary atherosclerosis, plaque composition, and clinical outcomes in acute coronary syndromes. JACC Cardiovasc Imaging 2012;5:S62-72.
7Roeters van Lennep JE, Zwinderman AH, Roeters van Lennep HW, Westerveld HE, Plokker HW, Voors AA, et al. Gender differences in diagnosis and treatment of coronary artery disease from 1981 to 1997. No evidence for the yentl syndrome. Eur Heart J 2000;21:911-8.
8Kalyani RR, Lazo M, Ouyang P, Turkbey E, Chevalier K, Brancati F, et al. Sex differences in diabetes and risk of incident coronary artery disease in healthy young and middle-aged adults. Diabetes Care 2014;37:830-8.
9Izadnegahdar M, Mackay M, Lee MK, Sedlak TL, Gao M, Bairey Merz CN, et al. Sex and ethnic differences in outcomes of acute coronary syndrome and stable angina patients with obstructive coronary artery disease. Circ Cardiovasc Qual Outcomes 2016;9:S26-35.
10Bajaj S, Mahajan V, Grover S, Mahajan A, Mahajan N. Gender based differences in risk factor profile and coronary angiography of patients presenting with acute myocardial infarction in North Indian population. J Clin Diagn Res 2016;10:OC05-7.
11Garg S, Sarno G, Girasis C, Vranckx P, de Vries T, Swart M, et al. A patient-level pooled analysis assessing the impact of the SYNTAX (synergy between percutaneous coronary intervention with taxus and cardiac surgery) score on 1-year clinical outcomes in 6,508 patients enrolled in contemporary coronary stent trials. JACC Cardiovasc Interv 2011;4:645-53.
12Zheng X, Dreyer RP, Hu S, Spatz ES, Masoudi FA, Spertus JA, et al. Age-specific gender differences in early mortality following ST-segment elevation myocardial infarction in china. Heart 2015;101:349-55.
13Leslee JS, Richard ES, Noel BM, Ralph GB, Lloyd WK, Brahmajee N, et al. On behalf of the American college of cardiology-national cardiovascular data registry investigators: Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American college of cardiology – National cardiovascular data registry. Circulation 2008;117:1787-801.
14Schulman-Marcus J, Hartaigh BÓ, Gransar H, Lin F, Valenti V, Cho I, et al. Sex-specific associations between coronary artery plaque extent and risk of major adverse cardiovascular events: The CONFIRM long-term registry. JACC Cardiovasc Imaging 2016;9:364-72.
15Numasawa Y, Kohsaka S, Miyata H, Noma S, Suzuki M, Ishikawa S, et al. Gender differences in in-hospital clinical outcomes after percutaneous coronary interventions: An insight from a Japanese multicenter registry. PLoS One 2015;10:e0116496.
16Fuchs FC, Ribeiro JP, Fuchs FD, Wainstein MV, Bergoli LC, Wainstein RV, et al. Syntax score and major adverse cardiac events in patients with suspected coronary artery disease: Results from a cohort study in a university-affiliated hospital in Southern Brazil. Arq Bras Cardiol 2016;107:207-15.
17Stefanini GG, Kalesan B, Pilgrim T, Räber L, Onuma Y, Silber S, et al. Impact of sex on clinical and angiographic outcomes among patients undergoing revascularization with drug-eluting stents. JACC Cardiovasc Interv 2012;5:301-10.
18Palmerini T, Genereux P, Caixeta A, Cristea E, Lansky A, Mehran R, et al. Prognostic value of the SYNTAX score in patients with acute coronary syndromes undergoing percutaneous coronary intervention: Analysis from the ACUITY (Acute catheterization and urgent intervention triage strategY) trial. J Am Coll Cardiol 2011;57:2389-97.
19Garg S, Serruys PW, Silber S, Wykrzykowska J, van Geuns RJ, Richardt G, et al. The prognostic utility of the SYNTAX score on 1-year outcomes after revascularization with zotarolimus- and everolimus-eluting stents: A substudy of the RESOLUTE all comers trial. JACC Cardiovasc Interv 2011;4:432-41.
20Wykrzykowska JJ, Garg S, Girasis C, de Vries T, Morel MA, van Es GA, et al. Value of the SYNTAX score for risk assessment in the all-comers population of the randomized multicenter LEADERS (Limus eluted from A durable versus ERodable stent coating) trial. J Am Coll Cardiol 2010;56:272-7.
21Scot G, Giovanna S, Patrick WS, Alfredo ER, Leonardo B, Maurizio A, et al. On behalf of the STRATEGY and MULTISTRATEGY investigators. Prediction of 1-year clinical outcomes using the SYNTAX score in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention a substudy of the STRATEGY (single high-dose bolus tirofiban and sirolimus-eluting stent versus abciximab and bare-metal stent in acute myocardial infarction) and MULTISTRATEGY (multicenter evaluation of single high-dose bolus tirofiban versus abciximab with sirolimus-eluting stent or bare-metal stent in acute myocardial infarction study) trials. J Am Coll Cardiol Intv 2011;4:66-75.
22Jacobs AK, Kelsey SF, Brooks MM, Faxon DP, Chaitman BR, Bittner V, et al. Better outcome for women compared with men undergoing coronary revascularization: A report from the bypass angioplasty revascularization investigation (BARI) Circulation 1998;98:1279-85.