Time is up for treatment inequity in women with acute coronary syndromes

Gender differences in symptom presentation and lack of patient awareness are the major causes of treatment delays in women when having an acute coronary syndrome (ACS). Despite repeated awareness campaigns in the USA and Europe, many women still do not expect to have such an event. Although the classic type of type 1 ACS occurs three times more often in men than in (elderly) women, the number of women under 65 years with ACS is gradually increasing.1 More adverse lifestyle factors and a persistent underestimation of cardiovascular risk in younger women contribute to this negative trend. As 30-day mortality rates are still higher in younger women with ST-segment elevation myocardial infarction (STEMI) and non-STEMI than in men, the need for more rapid recognition is urgent.2 However, the increasing rates of variant types of ACS in the younger female age group, now clustered under the diagnosis myocardial infarction with non-obstructive coronary arteries (MINOCA), importantly results in variable symptom presentation that may even more hamper timely recognition. In a report from the second largest percutaneous coronary intervention (PCI) centre in Switzerland, Meyer et al. confirm that patient and system delays in STEMI have improved over time, but a longer patient delay in women still exists.3 Within a large dataset of 3393 men and 967 women a 12% greater total ischaemic time was found. Mortality rates were higher in women, also in the younger age group aged less than 65 years. Among the patients who died during hospitalisation the total ischaemic time was 84% greater in women than in men. Although ACS-related symptoms were not recorded, the main conclusion from this registry is that women wait longer to call for medical help. It is unclear from the presented data how many interventions were performed in women compared with men and how often MINOCA was diagnosed. This flaws the data as differences in underlying pathophysiology may have contributed to a different clinical presentation. When vascular dysfunction and spasm are important mechanisms in ACS, as is often the case in younger women, symptoms can vary over time in a crescendo–decrescendo pattern. This can be very misleading in the interpretation of symptoms by the patient herself and her family. In the many awareness campaigns that have been conducted, more variable symptoms in women have been disseminated, but the fluctuating character of symptoms should also be emphasised. In the US National Registry of Myocardial Infarction it was shown that women more often than men report no chest pain at all (37% vs. 27%) during ACS.4 On a closer look younger women (<65 years) in particular more often had no chest pain or discomfort compared to elderly women.5 In contrast, in the SWEDEHEART register the absence of chest pain was more often found in women over 65 years.6 In the younger age group, however, the absence of chest pain resulted in higher mortality rates due to less intensive treatment. In addition, when no culprit lesions are found, such as in MINOCA, secondary prevention is often below average or even lacking.7 This has recently been confirmed in a large registry in the UK in which it was shown that women with ACS less often receive guideline-indicated care.8 The other side of the coin is that equal treatment among male and female patients is not always justified due to differences in the underlying pathophysiology. Women relatively more often have plaque erosions, type II ACS, spontaneous coronary artery dissections and coronary thrombi. They also have a higher bleeding risk after PCI and side effects of medications. In the VALIDATE-SWEDEHEART trial it was found that bivalirudin was associated with a lower risk of major bleeding in women compared to unfractionated heparin.9 In men no difference was found. With the abundant data currently present on sex and gender differences in ACS, we should not limit our focus to inequalities in access of care but we should practice more of what we preach. To achieve equity in care, we need to have the courage to implement more sex-specific knowledge and recommendations in our ACS guidelines to stop higher mortality and complication rates in our female population. As a first step, I would suggest to have more diversity in the guideline committees to guarantee much needed attention to equity of care. The author declares no conflict of interest.