Acute Coronary Syndromes in Premenopausal Women: A Scientific Statement From the American Heart Association

Premenopausal women presenting with acute coronary syndrome (ACS) are a unique and often underrecognized patient population. Although they are traditionally considered at lower cardiovascular risk than other groups, we have begun to appreciate the potential risk for ACS in this younger subset of women. Whereas atherosclerotic disease (obstructive or nonobstructive) accounts for most presentations, a substantial number are attributable to nonatherosclerotic causes, including spontaneous coronary artery dissection, epicardial coronary artery spasm, and coronary embolism. A major challenge at present is the lack of specific data and evidence for the diagnosis and management of these women. Unfortunately, as a result of several factors, diagnostic delays, misclassification, and mistreatment appear to be more frequent than for other patient groups. Of great concern, younger women less often receive guideline-directed therapies after ACS, and younger women with ACS have been shown to have worse outcomes than young men with ACS. Management should be tailored to the unique pathophysiology in premenopausal women, emphasizing early diagnosis, a low threshold for invasive angiography if appropriate, and special consideration in the pregnant patient. Secondary prevention must address traditional cardiovascular and disease-specific risk factors, with consideration of current or future pregnancies and lactation. Participation in cardiac rehabilitation is associated with improved outcomes and must be strongly encouraged, whereas attention to potential post-ACS depression and anxiety is an important aspect of holistic care. Increased patient and health care professional awareness and improved representation in research are critical to closing the knowledge and outcome gaps in premenopausal women with ACS.