Acute Coronary Syndrome in Women: An Update

Abstract

Purpose of review: The goal of this manuscript is to provide a concise summary of recent developments in the approach to and treatment of women with acute coronary syndrome (ACS).

Recent findings: This review covers terminology updates relating to ACS and myocardial injury and infarction. Updates on disparities in recognition, treatments, and outcomes of women with ACS due to atherosclerotic coronary artery disease are covered. Other causes of ACS, including spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary artery disease are discussed, given the increased frequency in women compared with men. The review summarizes the latest on the unique circumstance of ACS in women who are pregnant or post-partum, including etiologies, diagnostic approaches, medication safety, and revascularization considerations. Compared with men, women with ACS have unique risk factors, presentations, and pathophysiology. Treatments known to be effective for men with atherosclerosis-related ACS are also effective for women; further work remains on reducing the disparities in diagnosis and treatment. Implementation of multimodality imaging will improve diagnostic accuracy and allow for targeted medical therapy in the setting of myocardial infarction with non-obstructive coronary artery disease.

Keywords: Acute Coronary Syndromes; Atherosclerosis; Myocardial infarction with nonobstructive coronary artery disease; Sex-specific differences; Spontaneous coronary artery dissection.

Fig. 1

Possible causes of acute coronary syndrome (ACS) in women. Atherosclerotic plaque rupture or erosion may cause ST-elevation myocardial infarction or non-ST-elevation acute coronary syndrome. Other possible causes of ACS in women include spontaneous coronary artery dissection, coronary embolism, microvascular dysfunction, and coronary vasospasm. Multimodality imaging may uncover the underlying cause of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Fig. 2

Acute coronary syndromes in peripartum women. Physiologic and hormonal changes during the peripartum period are known risk factors for acute coronary syndrome in women. Potential etiologies include atherosclerotic plaque or coronary thrombosis and spontaneous coronary artery dissection (postpartum > intrapartum). While the evaluation and management of pregnant and nonpregnant women with acute coronary syndrome is similar, minimizing radiation exposure with collimation and abdominal shielding, positing pregnant patients with a left lateral tilt, and fetal monitoring are all important considerations in pregnancy