Sex differences in guideline-based pharmacological treatment after acute coronary syndrome with reduced ejection fraction

Background

Sex-related disparities in the management of acute coronary syndrome (ACS) have been widely reported, particularly regarding access to evidence-based therapies. In patients with left ventricular systolic dysfunction, optimal implementation of guideline-directed medical therapy (GDMT) is essential, yet contemporary data on sex differences in its use remain limited.

Methods

A single-center retrospective study including consecutive patients hospitalized with ACS and discharged with left ventricular ejection fraction (LVEF) ≤40%. Baseline characteristics, in-hospital management, discharge pharmacotherapy and complications were compared between women and men. Complete GDMT at discharge—defined as prescription of a β-blocker, ACE inhibitor or angiotensin receptor blocker, high-intensity statin and dual antiplatelet therapy—was the primary outcome. Independent predictors of GDMT prescription were assessed using multivariable logistic regression.

Results

The study population comprised 289 patients, of whom 23.2% were women. Women were significantly older than men (75.3 vs 68.0 years, p<0.001), had a higher prevalence of hypertension (82.1% vs 64.0%, p=0.005), and were less frequently active smokers (11.9% vs 31.5%, p=0.002). Prior myocardial infarction was less common among women (9.0% vs 25.8%, p=0.003). Angiographic findings differed, with left anterior descending artery culprit lesions more frequently identified in women (73.3% vs 51.7%, p=0.008), while rates of percutaneous coronary intervention were similar. Discharge LVEF did not differ between sexes (34.6% vs 34.1%, p=0.49).

During hospitalization, women more often received diuretics (80.6% vs 68.0%, p=0.047), with no significant differences in other acute therapies. At discharge, prescription rates of β-blockers, ACEi/ARB, statins and dual antiplatelet therapy were comparable between women and men, although diuretic use remained higher among women (78.6% vs 60.2%, p=0.011).

Complete GDMT was prescribed at similar rates in women and men (71.4% vs 70.9%, p=0.941). In multivariable analysis, sex was not independently associated with GDMT implementation (OR 1.30, p=0.469). Increasing age was the only independent predictor of incomplete GDMT prescription (OR 0.95 per year, p=0.003). Women experienced higher rates of new-onset atrial fibrillation and mechanical complications, whereas reinfarction, new-onset heart failure, cardiogenic shock, in-hospital mortality and one-year mortality were comparable between groups.

Conclusion

In this real-world cohort of ACS patients with reduced LVEF, GDMT prescription at discharge did not differ between women and men, despite marked differences in baseline characteristics and in-hospital complications. These findings suggest equitable application of guideline-recommended therapies, while underscoring the need to further explore whether uniform treatment strategies adequately address sex-specific clinical profiles.