CCTA-guided management of NSTE-ACS in women: a tailored diagnostic strategy

Background

In women presenting with acute coronary syndrome (ACS) without high-risk features, the underlying pathophysiology often differs from that observed in men. Women are less likely to exhibit obstructive coronary artery disease (CAD) and more frequently present with alternative mechanisms of myocardial injury, including spontaneous coronary artery dissection, stress (Takotsubo) cardiomyopathy, and coronary microvascular dysfunction.

In this context, coronary computed tomography angiography (CCTA) offers a valuable non-invasive approach, given its high sensitivity and negative predictive value for the exclusion of obstructive coronary artery disease.

Purpose

To analyze the role of CCTA in ACS in low and intermediate risk female patients.

Methods

436 female patients were evaluated with a protocol that includes the use of CCTA in ACS, among a total cohort of 1,001 patients. Women over 18 years of age with a diagnosis of ACS without ST elevation who did not meet high-risk criteria (hemodynamic instability, dynamic changes in the ST segment or T wave, ventricular arrhythmia, GRACE score >140, refractory angina, heart failure or cardiorespiratory arrest) and consulted the emergency department were included. Data collection was carried out between May 2022 and February 2026.

Results

436 female patients were included, with a mean age of 58 years. Among the admission diagnoses, 21% were NSTEMI and 79% were unstable angina. The median high-sensitivity cardiac troponin T value was 5 nanograms per litre (interquartile range, 3 to 12) for the first troponin sample, and 9 nanograms per litre (interquartile range, 6 to 29) for the second one. In 6% of patients, a CCTA was not obtained due to a high coronary artery calcium score (>400 AU). It was observed that 39% did not have any coronary lesions or plaques. 38% had non-obstructive coronary artery disease (plaques <50%). The rest had significant lesions in at least one vessel (16%) or were nondiagnostic (7%). 23% of the patients included underwent invasive coronary angiography and 11% required revascularisation.

Compared to men, women underwent significantly fewer invasive coronary angiographies (23.4% (102/436) vs 45.5% (257/565); RR=0.51; p<0.001) and required fewer revascularizations (11.0% (48/436) vs 32.6%(184/565); RR=0.34; p<0.001). Pearson’s chi-square test confirmed these differences were statistically significant (χ2=51.3 and 63.0 respectively, both p<0.001).

Conclusion

In this cohort, 77% of women with an NSTE-ACS had no significant obstructive lesions on CCTA. With a CCTA-guided strategy for low- to intermediate-risk NSTE-ACS, women demonstrated a markedly lower need for invasive coronary angiography and revascularization compared with men. This strategy could allow for a more tailored, precision-based and non-invasive approach that improves diagnostic yield while minimizing procedural risks and vascular injury.ICA and revascularization in women and menTable 1