Acute coronary syndromes: men and women - same species, same disease, same manifestation?

• DOI: 10.1093/ehjacc/zuaf044.076
• Publication Date: 2025-04-23T11:08:16Z
• Authors: C Pereira Mateus; I Miranda; F Gerardo; M Passos; J Lima Lopes; M Sarmento; R Brandao; D Roque

Abstract

Introduction Acute Coronary Syndromes (ACS), like many other disease spectra, exhibit differences not only in incidences in men and women but also in manifestation, treatment and prognosis.

Objectives This study aims to characterize ACS manifestation in both men and women.

Methods We conducted an observational study with retrospective analysis of all patients included between 2002 and 2019 in the Portuguese Registry of Acute Coronary Syndromes (ProACS), a voluntary, observational, prospective, continuous registry of the Portuguese Society of Cardiology and the National Center for Data Collection in Cardiology.

Results A total of 49,113 patients (34 936 men and 14 177 women) were included for analysis. Women with ACS were, on average, 8 years older than men (Table 1). The proportion of smoking women was smaller than that of men (8.5% vs 32.6%, p<0.001). However, women had a higher prevalence of obesity (23.8% vs 20.4%, p<0.001), hypertension (75.9% vs 60.4%, p<0.001), and diabetes (35.9% vs 26.0%, p<0.001). Women also had a more frequent previous history of stable angina (29.1% vs. 23.8%, p<0.001). Men had a higher incidence of ST-Elevation Myocardial Infarction (STEMI) than women, while women more frequently experienced Non-ST-Elevation Myocardial Infarction (NSTEMI) or Unstable Angina (Table 1). Chest pain was the predominant symptom in both genders, but women had a higher frequency of equivalent symptoms (dyspnea, fatigue, syncope) (Table 1). Men had fewer normal coronary angiographies (5.7% vs. 11.7%, p<0.001), yet women presented with higher Killip and GRACE scores, as well as intra-hospital adverse events, including heart failure, shock, mechanical complications, atrioventricular block, stroke, and death (Table 1).

Conclusion A compelling paradox is evident in our findings: despite having a higher prevalence of stable angina prior to hospital admission, and lower likelihood of obstructive lesions on coronary angiography, female patients experienced worse cases of ACS. This is evident in the elevated Killip and GRACE scores, pointing towards a worse prognosis, also reflected by this registry. This paradox prompts further explanation. While the older age of female patients with ACS and a higher prevalence of other comorbidities may offer some explanation, it raises intringuing questions about the interplay of various factors influencing the clinical course of ACS in men and women. In conclusion, this study reinforces the need for healthcare providers to move beyond a one-size-fits-all approach and consider the nuanced differences between genders in the diagnosis, treatment, and long-term management of ACS. Only through this nuanced understanding can we hope to bridge the gaps in outcomes and deliver more equitable and effective care to all patients.