Sex differences in the presentation and management of acute coronary syndrome patients: Insights from the FORCE-ACS registry

Aims: This study reports sex differences in the clinical presentation, treatment management and outcomes of patients with acute coronary syndrome (ACS) in The Netherlands, using data from the FORCE-ACS registry. Methods: A prospective analysis was conducted using data from 5023 patients admitted with ACS between 2015 and 2019, with complete three-year follow-up. Demographic data, clinical characteristics, in-hospital treatment and outcomes were compared by sex. Multivariable regression analyses explored associations between sex and clinical outcomes. Results: Of the 5023 patients, 29 % were women. Women were generally older, with a significantly higher prevalence of hypertension (61.7 % vs 54.2 %), chronic kidney disease (25.7 % vs. 18.5 %) and myocardial infarction with non-obstructive coronary arteries (MINOCA) (13.5 % vs. 6.5 %). Women less frequently underwent revascularisation, even after excluding those with non-obstructive coronary artery disease, and received less medical treatment compared to their male counterparts. At 36 months, women had higher unadjusted mortality rate (13.7 % vs. 11.0 %, OR 1.28, 95 % CI: 1.07-1.54) and bleeding events (26.2 % vs. 22.3 %, OR 1.24, 95 % CI: 1.08-1.43). However, after adjustment for age and baseline characteristics, these differences were no longer statistically significant. Recurrent ACS and stroke remained similar in both groups, also after correction. Conclusion: Differences between women and men were observed in clinical presentation, interventional treatment, pharmacotherapy and outcomes among ACS patients in The Netherlands. Despite receiving less guideline-recommended care, women had similar adjusted 36-month outcomes as men. These findings show that there is room for improvement in the management of ACS, with a focus on optimized treatment strategies for women.