Sex, age, and clinical presentation of acute coronary syndromes

Aim: To investigate sex differences in clinical presentation in younger and older patients hospitalised with a wide spectrum of acute coronary syndromes (ACS). Methods and results: We analysed 10 253 patients with a discharge diagnosis of ACS in the Euro Heart Survey of patients with Acute Coronary Syndromes. There were 1010 women and 3709 men <65 years. Among patients <65 years, fewer women than men presented with ST elevation, (OR [odds ratio]: 0.62 [0.53-0.71]) and developed Q-wave myocardial infarction (OR 0.58 [0.50-0.67]), whereas in patients ≥65 years there was no significant sex difference. Women <65 years were more likely than men of the same age to be discharged with a diagnosis of unstable angina (OR 1.56 [1.35-1.79]), but there was no sex difference in older patients; the p for interaction between sex and age for both was <0.0001. Among patients who underwent coronary angiography, both younger and older women were less likely than men to have 3-vessel or main stem disease. In a logistic regression analysis stratified for age, female sex was a significant negative determinant of presenting with ST elevation in patients <65 years (OR 0.68 [0.58-0.79]), whereas there was no effect of sex in patients ≥65 years. Conclusion: In younger patients with ACS, women were less likely than men to present with ST elevation and more likely to be discharged with a diagnosis of unstable angina. In older patients there were no differences in clinical presentation. Both older and younger women had less extensive atherosclerosis. The findings suggest a different pathophysiology of ACS in younger, but not older, women.