In industrialized countries, the incidence of coronary artery disease is three to four times higher in men than in women. Our review examines whether differences in the prevalence of, or susceptibility to, various coronary risk factors might con tribute to this sex differential. Cigarette smoking, hypertension, and hypercholesterolemia are risk factors for coronary artery disease in both sexes and are present at higher levels in middle-aged men than women. To date, such differences have failed to explain the coronary sex differential, although higher biological susceptibilities to smoking, blood pressure, and total cholesterol in men may also be important. Mean levels of protective high-density-lipoprotein cholesterol are higher in women than in men throughout life and may also contribute to the sex differential. In addition, men with a female pattern of abdominal fat distribution are at lower risk of coronary artery disease than those with a male pattern. In diabetic populations, the sex differential is greatly reduced, but studies on the effects of hyperinsulinemia and a lower insulin resistance in women compared with men are scarce. Prospective studies on the effect of fibrinogen and other hemostatic factors in women are also required.
