Acute coronary syndromes in women and men

Abstract

Evidence of sex-related disparities in the care and outcomes of patients with acute coronary syndrome (ACS) emerged >30 years ago, and yet the mechanisms behind these sex-specific differences remain unclear. In this Review, we discuss the current literature on differences between women and men in the clinical presentation, pathophysiology, evaluation, management, and outcomes of ACS. Although the symptoms of ACS and the benefits of therapy generally overlap between women and men, women continue to receive less-aggressive invasive and pharmacological therapy than men. In addition, young women in particular have worse short-term and long-term outcomes than men. To understand better the mechanisms behind these continued disparities, we have identified areas of future research that need to be urgently addressed in fields that range from clinical evaluation and management, to increasing representation of women in research.

Figure 1 |. Sex-specific differences in baseline risk factors for ACS.

Women have higher rates than men of traditional risk factors such as diabetes mellitus, hypertension, and obesity, and have differential lifestyle and psychosocial determinants. In addition, women have sex-specific risk factors such as pregnancy and menopause. ACS, acute coronary syndrome; MI, myocardial infarction; STEMI, non-ST-segment elevation myocardial infarction.

Figure 2 |. Sex-specific differences in the pathophysiology of acute coronary syndrome.

A substantial proportion of acute coronary syndrome cases, especially in women, are caused by mechanisms other than plaque rupture and thrombus formation. Plaque erosion, coronary vasospasm, spontaneous coronary artery dissection, and stress-related (Takotsubo) cardiomyopathy are more prevalent in women than in men.