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Evidence base for the management of women with non-ST elevation acute coronary syndrome
  1. James Jackson1,
  2. Mohammad Alkhalil1,2,
  3. Hanna Ratcovich1,
  4. Chris Wilkinson2,3,
  5. Roxana Mehran4,
  6. Vijay Kunadian1,2
  1. 1Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
  2. 2Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  3. 3Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
  4. 4The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Dr Vijay Kunadian, Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, Newcastle upon Tyne, UK; vijay.kunadian{at}


According to the Global Burden of Disease study, in 2019, there were an estimated 275.2 million cases of cardiovascular disease (CVD) in women worldwide. Although there was a decrease in the global age-standardised prevalence of CVD in women between 1990 and 2010 (–5.8%), there has been a slight increase (1.0%) since 2010. There were an estimated 6.10 million deaths from CVD in women in 1990, rising to 8.94 million in 2019. Hospital admissions of young women with acute myocardial infarction (AMI) steadily increased from 27% in 1995–1999 to 32% in 2010–2014. Women with AMI compared with men are less likely to receive guideline-indicated pharmacological (aspirin 93.4% vs 94.7%, P2Y12 inhibitors 79.3% vs 86.1% and statins 73.7% vs 77.5%) and revascularisation treatments (angiography (adjusted OR (aOR) 0.71), percutaneous coronary intervention (aOR 0.73)). Women represent <39% of clinical cardiovascular trial participants between 2010 and 2017. Major factors of under-representation in studies included concerns about the burden of participation on health and time. Women were more likely than men to document caring responsibilities as reasons for not participating in a clinical trial. Current clinical practice guidelines recommending risk stratification to guide the appropriateness of an invasive strategy in the context of acute coronary syndrome (ACS) may not be applicable to women given lack of studies specifically evaluating women using contemporary treatment strategies. In our review, we identify significant limitations in the evidence base for the best care of women with ACS, emphasising the need for well-designed clinical trials specifically recruiting women.

  • coronary angiography
  • coronary artery disease
  • acute coronary syndrome
  • atherosclerosis
  • myocardial infarction

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  • Contributors VK: conceived the idea, undertook multiple revisions. JJ: wrote the initial draft and undertook multiple revisions. MA, CW, HR and RM provided critical review.

  • Funding VK is supported by the British Heart Foundation Clinical Study Grant (CS/15/7/316), Newcastle NIHR Biomedical Research Centre and Institutional Research Grant from AstraZeneca (ISSBRIL0303).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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