Sex affects care and prognosis in acute coronary syndrome

Background

This study examines sex-specific differences in patients with acute coronary syndrome (ACS), utilising data drawn from the Hungarian National Myocardial Infarction Register. The analysis spans a decade and includes 179,386 individuals, with all-cause mortality evaluated alongside major risk factors and treatment outcomes.

Methods

Patient data reporting for ACS has been mandatory in Hungary since January 2014. This retrospective investigation encompasses all cases recorded from the registry’s inception through to 2024, with a mean follow-up of 3.8 years. The principal outcome measured was all-cause mortality. Propensity score matching (PSM) was conducted using a 1:1 nearest neighbour algorithm, with age, ACS subtype, percutaneous revascularisation, and diabetes mellitus as fixed covariates to account for baseline clinical disparities.

Results

The study included 179,386 patients, with a median age of 68 years and a male proportion of 60.5%. Mortality across all intervals was significantly affected by age, diabetes, and ACS subtype. Female patients exhibited higher incidences of diabetes, hypertension, and were generally older; they also experienced more complications related to myocardial infarction. In contrast, male patients were more likely to have undergone prior interventions, received timelier treatment, and had a greater rate of percutaneous coronary intervention (PCI). Women were less frequently discharged with guideline-recommended drug therapies and had greater observed, unadjusted mortality at each evaluated time point (47.9% vs. 39.3%, p < 0.001).

The PSM procedure achieved high quality balance (Mean Bias: 2.5%, Rubin’s B: 6.5) and revealed that the previously observed poorer prognosis among women was attenuated. Adjusted for these clinical variables, women demonstrated a 10.3 percentage point lower all-cause mortality compared to men (Average Treatment effect on the Treated [ATT] = -0.103; t = -22.83; p < 0.001). The robustness of these findings was confirmed by the Rosenbaum sensitivity test, showing that the effect remained significant (p < 0.001) even at a Gamma sensitivity level of 2.0, indicating the effect persisted despite potential unmeasured confounding factors.

Conclusion

Substantial sex-related disparities in ACS management and prognosis remain evident. The unfavourable outcomes observed in female patients underscore the necessity for individualised, equitable, and prompt care, with clinical guidelines evolving to consider the interplay between age, sex, and comorbidities. According to our analysis, these differences are largely attributable to older age, greater comorbidity burden, and reduced rates of revascularisation among women. When adjusted for these factors, the female sex was associated with a significant survival advantage. Enhancing access, raising awareness, and pursuing continued research are vital to optimise ACS care and address existing gaps.