{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T09:31:33Z","timestamp":1786699893599,"version":"build-2736575974"},"reference-count":33,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T00:00:00Z","timestamp":1786665600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Cardiovasc. Dev. Dis.","JCDD"],"abstract":"<jats:p>Cardiovascular disease remains the leading cause of death among women, yet female cardiovascular risk continues to be underrecognized, and women remain underrepresented in many cardiovascular trials. Sex-related differences in hormonal exposure, immune regulation, vascular function, pregnancy-related conditions, and clinical presentation contribute to heterogeneity in cardiovascular disease across the life course. Statins reduce atherosclerotic cardiovascular events in women and men, with no consistent evidence of treatment-effect heterogeneity by sex. In addition to lowering low-density lipoprotein cholesterol, statins influence inflammatory signaling, endothelial nitric oxide bioavailability, oxidative stress, thrombosis, and plaque biology. These effects are biologically relevant to atherosclerosis; however, current clinical evidence does not establish that LDL-independent statin effects confer a uniquely greater benefit in women. Historical pathological studies suggested that plaque erosion may contribute relatively more often to acute coronary thrombosis in selected younger women, whereas contemporary optical coherence tomography studies show similar overall frequencies of plaque rupture and erosion between sexes and important age-related variation. Evidence for a female-specific effect of statins on post-myocardial infarction remodeling, cognition, or pharmacogenomic susceptibility is also insufficient. This narrative review distinguishes established clinical evidence from mechanistic plausibility and unresolved sex-specific hypotheses. It emphasizes equitable implementation of guideline-directed lipid-lowering therapy, careful evaluation of statin-associated symptoms, and the need for adequately powered studies reporting sex-stratified estimates and formal treatment-by-sex interactions.<\/jats:p>","DOI":"10.3390\/jcdd13080389","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T08:08:29Z","timestamp":1786694909000},"page":"389","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Inflammation, Statin Pleiotropy, and Cardiovascular Prevention in Women: Established Evidence, Biological Plausibility, and Knowledge Gaps"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-1467-4692","authenticated-orcid":false,"given":"Rogerio","family":"Castellan de Moraes","sequence":"first","affiliation":[{"name":"Postgraduate Department, Universidade Nove de Julho (UNINOVE), S\u00e3o Paulo 01504-001, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6723-5758","authenticated-orcid":false,"given":"Paulo Magno","family":"Dourado","sequence":"additional","affiliation":[{"name":"Hypertension Unit, Heart Institute of Medical School, University of S\u00e3o Paulo, S\u00e3o Paulo 05403-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Viviane Zorzanelli","family":"Rocha","sequence":"additional","affiliation":[{"name":"Hypertension Unit, Heart Institute of Medical School, University of S\u00e3o Paulo, S\u00e3o Paulo 05403-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9591-3093","authenticated-orcid":false,"given":"Heno Ferreira","family":"Lopes","sequence":"additional","affiliation":[{"name":"Hypertension Unit, Heart Institute of Medical School, University of S\u00e3o Paulo, S\u00e3o Paulo 05403-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernanda Marciano","family":"Consolim-Colombo","sequence":"additional","affiliation":[{"name":"Postgraduate Department, Universidade Nove de Julho (UNINOVE), S\u00e3o Paulo 01504-001, Brazil"},{"name":"Hypertension Unit, Heart Institute of Medical School, University of S\u00e3o Paulo, S\u00e3o Paulo 05403-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2385","DOI":"10.1016\/S0140-6736(21)00684-X","article-title":"The Lancet women and cardiovascular disease Commission: Reducing the global burden by 2030","volume":"397","author":"Vogel","year":"2021","journal-title":"Lancet"},{"key":"ref_2","first-page":"815","article-title":"Position statement on women\u2019s cardiovascular health\u20142022","volume":"119","author":"Costa","year":"2022","journal-title":"Arq. Bras. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1126\/science.adx4381","article-title":"Sex differences in tissue-specific immunity and immunology","volume":"389","author":"Sharma","year":"2025","journal-title":"Science"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1583","DOI":"10.1126\/science.1112062","article-title":"Molecular and cellular basis of cardiovascular sex differences","volume":"308","author":"Mendelsohn","year":"2005","journal-title":"Science"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Cholesterol Treatment Trialists\u2019 Collaboration, Fulcher, J., O\u2019Connell, R., Voysey, M., Emberson, J., Blackwell, L., Mihaylova, B., Simes, J., Collins, R., and Kirby, A. (2015). Efficacy and safety of LDL-lowering therapy among men and women: Meta-analysis of individual data from 174,000 participants in 27 randomised trials. Lancet, 385, 1397\u20131405.","DOI":"10.1016\/S0140-6736(14)61368-4"},{"key":"ref_6","first-page":"e1082","article-title":"2018 AHA\/ACC guideline on the management of blood cholesterol","volume":"139","author":"Grundy","year":"2019","journal-title":"Circulation"},{"key":"ref_7","unstructured":"GBD 2019 Diseases and Injuries Collaborators (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u20132019. Lancet, 396, 1204\u20131222."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1047","DOI":"10.1161\/CIRCULATIONAHA.118.037137","article-title":"Twenty-year trends and sex differences in young adults hospitalized with acute myocardial infarction","volume":"139","author":"Arora","year":"2019","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"932","DOI":"10.1093\/eurheartj\/ehn018","article-title":"Risk factors for myocardial infarction in women and men: Insights from the INTERHEART study","volume":"29","author":"Anand","year":"2008","journal-title":"Eur. Heart J."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1297","DOI":"10.1016\/S0140-6736(11)60781-2","article-title":"Cigarette smoking as a risk factor for coronary heart disease in women compared with men: A systematic review and meta-analysis","volume":"378","author":"Huxley","year":"2011","journal-title":"Lancet"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1210\/edrv.23.1.0456","article-title":"Changes in proinflammatory cytokine activity after menopause","volume":"23","author":"Pfeilschifter","year":"2002","journal-title":"Endocr. Rev."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2087","DOI":"10.1056\/NEJMoa2405182","article-title":"Inflammation, cholesterol, lipoprotein(a), and 30-year cardiovascular outcomes in women","volume":"391","author":"Ridker","year":"2024","journal-title":"N. Engl. J. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2195","DOI":"10.1056\/NEJMoa0807646","article-title":"Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein","volume":"359","author":"Ridker","year":"2008","journal-title":"N. Engl. J. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2825","DOI":"10.1016\/j.jacc.2010.01.054","article-title":"Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia","volume":"55","author":"Pepine","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2727","DOI":"10.1093\/eurheartj\/ehaf1059","article-title":"Sex and gender differences in coronary pathophysiology and ischaemic heart disease","volume":"47","author":"Manfrini","year":"2026","journal-title":"Eur. Heart J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e011612","DOI":"10.1161\/CIRCINTERVENTIONS.121.011612","article-title":"Sex differences in culprit plaque characteristics among different age groups in patients with acute coronary syndromes","volume":"15","author":"Seegers","year":"2022","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1007\/s11239-019-01969-9","article-title":"Relative risk of plaque erosion among different age and sex groups in patients with acute coronary syndrome","volume":"49","author":"Kim","year":"2020","journal-title":"J. Thromb. Thrombolysis"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"III39","DOI":"10.1161\/01.CIR.0000131517.20177.5a","article-title":"Beneficial cardiovascular pleiotropic effects of statins","volume":"109","author":"Davignon","year":"2004","journal-title":"Circulation"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1161\/CIRCRESAHA.116.308537","article-title":"Pleiotropic effects of statins on the cardiovascular system","volume":"120","author":"Oesterle","year":"2017","journal-title":"Circ. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1001\/jama.286.1.64","article-title":"Effect of statin therapy on C-reactive protein levels: The PRINCE randomized trial","volume":"286","author":"Albert","year":"2001","journal-title":"JAMA"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1056\/NEJMoa1707914","article-title":"Antiinflammatory therapy with canakinumab for atherosclerotic disease","volume":"377","author":"Ridker","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2497","DOI":"10.1056\/NEJMoa1912388","article-title":"Efficacy and safety of low-dose colchicine after myocardial infarction","volume":"381","author":"Tardif","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1838","DOI":"10.1056\/NEJMoa2021372","article-title":"Colchicine in patients with chronic coronary disease","volume":"383","author":"Nidorf","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2981","DOI":"10.1161\/01.CIR.101.25.2981","article-title":"Left ventricular remodeling after myocardial infarction","volume":"101","author":"Sutton","year":"2000","journal-title":"Circulation"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1146\/annurev.pharmtox.45.120403.095748","article-title":"Pleiotropic effects of statins","volume":"45","author":"Liao","year":"2005","journal-title":"Annu. Rev. Pharmacol. Toxicol."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"SEARCH Collaborative Group, Link, E., Parish, S., Armitage, J., Bowman, L., Heath, S., Matsuda, F., Gut, I., Lathrop, M., and Collins, R. (2008). SLCO1B1 variants and statin-induced myopathy\u2014A genomewide study. N. Engl. J. Med., 359, 789\u2013799.","DOI":"10.1056\/NEJMoa0801936"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1002\/cpt.2557","article-title":"CPIC guideline for SLCO1B1, ABCG2, and CYP2C9 and statin-associated musculoskeletal symptoms","volume":"111","author":"Niemi","year":"2022","journal-title":"Clin. Pharmacol. Ther."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1161\/CIRCRESAHA.118.312782","article-title":"Statin toxicity: Mechanistic insights and clinical implications","volume":"124","author":"Ward","year":"2019","journal-title":"Circ. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1507","DOI":"10.1056\/NEJMoa1912387","article-title":"Two phase 3 trials of inclisiran in patients with elevated LDL cholesterol","volume":"382","author":"Ray","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1353","DOI":"10.1056\/NEJMoa2215024","article-title":"Bempedoic acid and cardiovascular outcomes in statin-intolerant patients","volume":"388","author":"Nissen","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1775","DOI":"10.1161\/CIRCULATIONAHA.123.067691","article-title":"Impact of bempedoic acid on cardiovascular outcomes by sex","volume":"149","author":"Cho","year":"2024","journal-title":"Circulation"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e70288","DOI":"10.1002\/clc.70288","article-title":"Sex differences in statin intolerance: Insights from the CLEAR Outcomes trial","volume":"49","author":"Naderi","year":"2026","journal-title":"Clin. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1038\/nrneurol.2015.35","article-title":"Statins, cognition, and dementia: Systematic review and methodological commentary","volume":"11","author":"Power","year":"2015","journal-title":"Nat. Rev. Neurol."}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/8\/389\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T08:46:56Z","timestamp":1786697216000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/8\/389"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,14]]},"references-count":33,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["jcdd13080389"],"URL":"https:\/\/doi.org\/10.3390\/jcdd13080389","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,14]]}}}