Gender Differences in the Epidemiology, Clinical Presentation, Prevention, and Prognosis of Acute Coronary Syndromes

In this issue of Angiology, Shehab et al 1 describe gender differences in cardiovascular (CV) risk factors, clinical manifestations, treatment, and short-term prognosis in patients admitted with acute coronary syndrome (ACS).Women were older and had higher prevalence of hypertension, dyslipidemia, and diabetes.1 Obesity was more frequent in women, while smoking was more frequent in men. 1 In-hospital mortality and complications were greater in women than in men. 1 There are several points of interest in this study.In the general population, coronary heart disease (CHD) affects men more than women.2 For example, in the United States its prevalence was 37.4% in men and 35.0% in women, in 2008.3 Different distribution of various CV risk factors was suggested between men and women with CHD.2,3 Epidemiological studies, including the Framingham study, showed that CHD presents at an earlier age in men than in women.4,5 The INTERHEART study included 12 461 patients with a first myocardial infarction (MI) and 14 637 age-and sexmatched controls from 52 countries.6 Among these, 6787 were women.6,7 Women with MI were older than men (median age 65 vs 56 years, P < .0001)7 .Also, men were more likely to have MI before the age of 60 than women (a difference of 27.6% in the predictive probability).7 This gender-related difference was alleviated by >80% after the adjustment for 9 modifiable CV risk predictors.7 These included smoking, exercise, alcohol abuse, fruit and vegetable consumption, hypertension, diabetes, abdominal obesity, psychosocial factors, and increased apolipoprotein (apo) B/apoA1 ratio.7 This finding implied that the earlier age of MI in men reflects the higher levels of several risk factors, such as smoking, which men possess in younger ages.7 Therefore, the higher prevalence of smoking in men in the Shehab et al 1 study could at least in part explain the gender-related difference in the age of ACS occurrence.Younger women benefit from the protective effects of endogenous estrogens, including estradiol.8 Estradiol inhibits many processes involved in age-related vascular remodeling.8 These include vascular smooth muscle cell proliferation and endothelial dysfunction.8 Furthermore, estradiol lowers cholesterol levels and improves the vascular tone.9,10 On the other hand, menopause has been recognized as a risk factor for CV disease