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 guidelinerecommended 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.