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Acute coronary syndromes
Management of acute coronary syndromes: special considerations in women
  1. Stephanie M Madonis1,
  2. Kimberly A Skelding2,
  3. Madhur Roberts3
  1. 1 Department of General Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
  2. 2 Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA
  3. 3 Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
  1. Correspondence to Dr Kimberly A Skelding, Department of Cardiology, Geisinger Medical Center, 100 North Academy Avenue Danville, PA 17822, USA; kaskelding{at}

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Learning objectives

  • Explore the impact of sex on morbidity and mortality from acute coronary syndrome.

  • Explore sex-based differences in pathophysiology, presentation and diagnosis of acute coronary syndrome.

  • Identify sex-based disparities in evidence-based treatment guidelines.

  • Recognise the need for sex-based research in acute coronary syndrome.


Since 1984, more women than men have died annually in the USA from cardiovascular disease (CVD).1 Women with coronary artery disease (CAD) have worse outcomes when no adjustments are made for other characteristics and co-morbidities.2 Acute coronary syndrome (ACS) is a subset of CAD, characterised by an abrupt onset of signs and symptoms of myocardial ischaemia. It is associated with rupture or erosion of an atherosclerotic plaque that results in either the partial or complete occlusion of the infarct-related artery. ACS requires rapid assessment, diagnosis and treatment to achieve optimal outcomes.

Enormous advances have been made in ACS management; however, significant sex-related disparities persist resulting in suboptimal treatment of women. This inconsistency continues to be significant even when education, income and site of care are taken into consideration.3 Although many reasons have been elucidated to explain this disparity, much remains unclear. Differences could be explained in part by the pathophysiology of CAD in men and women. For example, women with ACS are less likely to have significant obstructive CAD but are more likely to have thrombus formation and plaque erosion when compared with men with similar symptoms.4 5

Additionally, differences exist regarding treatment and management leading to deferment of evidence-based therapies in women. Women continue to be under-represented in cardiovascular trials and on average comprise only 25% of clinical investigations in ACS.6 Fortunately, as awareness of this important issue increases, more research is being done to reveal sex-specific aspects of care. The goal of this review is to highlight differences in therapy and …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note In the reference list papers with a * are highlighted as a key reference.