Gender Differences and Acute Coronary Syndrome: The Clinical Implications

A new review finds a range of disparities in how men and women with ACS symptoms are treated and indicates that women who present with symptoms suggesting ACS need to be treated more aggressively.

Ischemic heart disease (IHD) is the most frequent cardiovascular cause of death among men and women, causing more than half of all cardiovascular events. In pre-menopausal women, IHD’s onset occurs on average about 10 years later than in men. Myocardial infarction occurs on average 20 years later in premenopausal women than in men. After menopause, the incidence of IHD in women increases significantly. This may be due to declining estrogen levels, which suggests that hormone replacement therapy may be beneficial. However, results from the randomized controlled Women’s Health Initiative (WHI) indicate otherwise. This highlights gender-related cardiovascular disease’s metabolic complexity.

In addition, studies have shown that clinicians tend to treat women exhibiting symptoms congruent with IHD less aggressively than they treat men with similar symptoms. This gender bias extends to the decision to recommend patients for coronary artery bypass surgery. A review published online on June 11, 2013, in the British Journal of Pharmacology of the ample data covering gender differences in IHD and acute coronary syndrome (ACS) reveals the following discrepancies:

• Young women more frequently have ACS with angiographically “normal” coronary arteries compared with men.
• Most research indicates that women experience higher mortality after ACS compared with men.
• Women presenting with ACS tend to be older and more likely to have hypertension, diabetes, and metabolic syndrome than men.
• Women are less likely to undergo coronary revascularization for ACS than men, but have similar survival and re-infarction rates to men when they do.
• Clinicians prescribe beta-blockers less frequently for women than for men, but women who are prescribed beta-blockers achieve higher plasma levels and exhibit a more pronounced decrease in heart rate and systolic blood pressure than do men who are prescribed beta-blockers.
• Women are less likely to receive ACE-inhibitors or angiotensin II type-1 receptor blockers as part of ACS treatment, but when they do, the likelihood of cardiovascular-related death decreases significantly.
• Women with ACS also receive statins less often than men, an intervention that has significant potential benefit.

The clinical implications of the review’s findings are pressing. Women who present with symptoms suggesting ACS need to be treated aggressively and in accordance with current clinical guidelines. Pharmacists should ask about adding beta-blockers, ACE-inhibitors, or angiotensin II type-1 receptor blockers as well as statins to patients’ drug regimens if they seem to have been overlooked.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.