Outcomes for Men and Women After NSTE-ACS

Study Questions:

Are women at increased risk for adverse outcomes after non–ST-segment elevation acute coronary syndromes (NSTE-ACS)?


Data were analyzed from 10 TIMI (Thrombolysis in Myocardial Infarction) trials that each enrolled >2,500 patients within 30 days of hospitalization for NSTE-ACS. The association of sex with major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, or stroke) was analyzed by Cox proportional hazard ratio models and controlled for risk factors. Point estimates were combined using random-effects models.


Of 68,730 patients, 19,827 (29%) were women. Compared with men, women were more likely to be older, diabetic, hypertensive, and have heart failure and renal dysfunction. Overall, without adjustment for risk factors, women were at similar risk of MACE (hazard ratio [HR], 1.04; 95% confidence interval [CI], 0.99-1.09; p = 0.16) and at higher risk of all-cause death (HR, 1.12; 95% CI, 1.01-1.24; p = 0.03). After adjustment for confounding risk factors, women were at lower risk of MACE (HR, 0.93; 95% CI, 0.88-0.98; p < 0.01) and all-cause death (HR, 0.84; 95% CI, 0.78-0.90; p < 0.0001) compared with men.


After NSTE-ACS, women had a similar unadjusted risk of MACE and a higher risk of death; however, after controlling for confounding risk factors, women had a lower risk of MACE and death than men.


This was a large study including data from 10 TIMI trials. Prior studies have suggested that women with ACS are at increased risk for adverse events compared with men. This study found that after controlling for confounding risk factors, women are actually at a lower risk for adverse events and death. Therefore, adverse outcomes are more likely related to high rates of associated comorbidities rather than intrinsic biological factors related to the female sex itself. Efforts to address risk factors that are prevalent in women may help to improve outcomes after ACS.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Acute Coronary Syndrome, Comorbidity, Diabetes Mellitus, Heart Failure, Hypertension, Myocardial Infarction, Outcome Assessment (Health Care), Renal Insufficiency, Risk Factors, Secondary Prevention, Stroke, Women

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