Sex-Based Differences in Acute Coronary Syndromes

Acute coronary syndromes (ACS) may result from atherosclerotic or nonatherosclerotic mechanisms, and commonly but not always present as plaque rupture. Women presenting with ACS are more often older than men with several pre-existing comorbidities. Although the protective influence of estrogen is notable in younger women, it is over-ridden by the presence of risk factors resulting in worse outcomes for young women with ACS compared with young men. Similarly the morbidity of angiographically nonobstructive disease is greater in women, leading to recurrent angina and hospitalization. ACS resulting from nonatherosclerotic mechanisms requires rigorous investigation for appropriate management. Although cost and logistics deter the routine use of invasive coronary imaging during cardiac catheterization, careful clinical considerations are warranted to guide optimal usage in practice. This review will discuss the insights into sex-based differences obtained chiefly from invasive coronary imaging with a focus on ACS.