Sex differences in presentation, care quality, and outcomes of NSTEMI


In a prospective cohort study, women hospitalized with NSTEMI were older and had a higher comorbidity burden than men. Still, women were less likely to receive coronary angiography, smoking cessation advice, and antiplatelet prescriptions.

This summary is based on the publication of Nadarajah R et al. - Sex-specific presentation, care, and clinical events in individuals admitted with NSTEMI: the ACVC-EAPCI EORP NSTEMI registry of the European Society of Cardiology. Eur Heart J Acute Cardiovasc Care. 2023 Oct 31:zuad134. doi: 10.1093/ehjacc/zuad134.

Introduction and methods


Women have a worse prognosis after NSTEMI [1,2], possibly due to sex-dependent discrepancies in the provision of guideline-recommended care in routine practice [1,3-5]. However, previous observational studies reporting variation in care quality and outcomes for NSTEMI by sex have limitations. For example, they relied on old data [1,2,5], were not limited to type I MI [1,2], or lacked information on invasive coronary angiography (ICA) findings [2].

Aim of the study

The authors aimed to identify patterns of presentation, care quality, and outcomes of NSTEMI stratified by sex in a contemporary and geographically diverse cohort.


In this prospective, international, multicenter, observational cohort study, data for 2947 patients (907 women, 2040 men) were collected from the ACVC-EAPCI EORP NSTEMI registry of the European Society of Cardiology (ESC). These consecutive patients were hospitalized with a final diagnosis of type I NSTEMI within a 2-week period at each center. Quality of care was evaluated based on 12 ESC Guideline–recommended NSTEMI care interventions . These interventions were: pre-hospitalization receipt of aspirin, aspirin at discharge, P2Y₁₂ inhibitor at discharge, ACEi/ARB at discharge, beta-blocker at discharge, statin at discharge, ECG pre- or in-hospital, echocardiography, ICA, referral to cardiac rehabilitation, smoking cessation advice, and dietary advice.


Outcomes included investigator-reported in-hospital episodes of acute HF, cardiogenic shock, use of mechanical circulatory support, repeat MI, stroke/TIA, BARC type ≥3 bleeding, and all-cause mortality, as well as 30-day mortality.

Main results


  • Compared with men, women admitted with NSTEMI were older, were more often obese (BMI ≥30 kg/m²), and had a higher burden of CV comorbidities, such as hypertension, diabetes, and hypercholesterolemia, but less frequently a history of prior MI or revascularization.
  • Nearly twice as many female patients presented with CKD stage ≥3 (i.e., eGFR <60 mL/min/ 1.73 m²: 39.6% vs. 21.4%; P<0.001).
  • In addition, women were more often at higher mortality risk (GRACE risk score >140: 54.0% vs. 41.7%; P<0.001) and higher bleeding risk (CRUSADE risk score >40: 51.7% vs. 17.6%; P<0.001) risk compared with men.

Quality of care

  • More than 90% of the female and male patients were prescribed aspirin and statins at the time of discharge. However, women less frequently received ICA (83.0% vs. 89.5%; P<0.001), smoking cessation advice (46.4% vs. 69.5%; P<0.001), and P2Y₁₂ inhibitor prescription at discharge (81.9% vs. 90.0%; P<0.001).
  • Of the reasons for not performing ICA, only “the procedure felt inappropriate due to frailty” was recorded significantly more often for women than men (16.7% vs. 7.8%; P=0.010). Of those who did undergo ICA, a higher proportion of women had either nonobstructive coronary artery disease or angiographically normal arteries compared with men (15.8% vs. 6.3%; P < 0.001).
  • Receipt of optimal care was lower in women than men (≥80% of eligible interventions achieved: 55.8% vs. 62.4%; P<0.001).


  • The rate of in-hospital acute HF was numerically, albeit not statistically significantly, higher in women than men (11.6% vs. 9.4%; P=0.071).
  • A higher proportion of women was treated with diuretics during their hospital stay (41.8% vs. 32.5%; P<0.001) and at discharge (34.8% vs. 27.3%; P<0.001), although LV systolic function metrics did not vary by sex across the cohort.
  • Rates of other (crude) in-hospital adverse outcomes and 30-day mortality were low and similar across sex.


This prospective observational cohort study showed that women hospitalized with NSTEMI were older, had a higher comorbidity burden, and had increased mortality and bleeding risks compared with men. Female patients less frequently underwent ICA due to concerns of frailty and more often had nonobstructive coronary artery disease or angiographically normal coronary arteries. Finally, women less frequently received smoking cessation advice and antiplatelet prescriptions. There were no differences in in-hospital and 30-day mortality rates between the sexes.

The authors conclude their findings “imply further steps [need] to be taken to improve care for women who experience NSTEMI. [...] We provide further evidence for the significant burden of myocardial infarction in the absence of obstructive coronary artery disease in women presenting with Type I myocardial infarction without ST-segment elevation.”


1. Alabas OA, Gale CP, Hall M, Rutherford MJ, Szummer K, Lawesson SS, et al. Sex differences in treatments, relative survival, and excess mortality following acute myocardial infarction: national cohort study using the SWEDEHEART registry. J Am Heart Assoc 2017;6:e007123.

2. Wilkinson C, Bebb O, Dondo TB, Munyombwe T, Casadei B, Clarke S, et al. Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study. Heart 2019;105:516–523.

3. Jackson J, Alkhalil M, Ratcovich H, Wilkinson C, Mehran R, Kunadian V. Evidence base for the management of women with non-ST elevation acute coronary syndrome. Heart 2022;108:1682–1689.

4. Araújo C, Pereira M, Laszczyńska O, Dias P, Azevedo A. Sex-related inequalities in management of patients with acute coronary syndrome—results from the EURHOBOP study. Int J Clin Pract 2018;72:e13049.

5. Rashid M, Fischman DL, Gulati M, Tamman K, Potts J, Kwok CS, et al. Temporal trends and inequalities in coronary angiography utilization in the management of non-ST-elevation acute coronary syndromes in the US. Sci Rep 2019;9:240.

Find this article online at Eur Heart J Acute Cardiovasc Care.

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