ABC | Volume 111, Nº5, November 2018

Original Article Soeiro et al ACS in Men vs. women Arq Bras Cardiol. 2018; 111(5):648-653 Regardless the treatment strategy, either with thrombolytic therapy or PCI, women generally have worse outcomes than men. These data become controversial, as women have a more favorable outcome with PCI compared to thrombolytic therapy in the STE-ACS scenario and clearly benefit from an early invasive strategy in any situation. 1,8,12,14 As an example, a registry published in 2007 on patients with ACS showed that women underwent PCI less frequently than men (Odds Ratio – OR = 0.65; 95% Confidence Interval – 95%CI: 0,61‑0,69), and their in-hospital mortality showed a worse index (10.7% vs. 6.3%, p < 0.001). 1 This description in the literature is once again reinforced by the data from our study, showing higher rates of surgical and percutaneous revascularization in men. The most plausible explanation for this scenario is that women are more likely to have unusual pathophysiological mechanisms of coronary disease, such as spontaneous coronary artery dissection or coronary artery spasm. Furthermore, the fact that they have more comorbidities, such as diabetes and dyslipidemia, favors the occurrence of lesions in thinner vessels and more extensive lesions. 2 Finally, in the present study, we did not find any prognostic differences, either in-hospital or in the medium term, between the genders in our population. Some studies follow the same line and also have not shown any significant differences between the genders regarding mortality in ACS. 6,8,9,11,13 Reinforcing our finding, a study published in 2012 with 1,640 patients with ACS showed no differences in cardiovascular mortality according to gender (1.3% vs. 2.7%, p=0.18) at the end of one year after PCI for men andwomen, respectively. 13 Finding similar mortality rates betweenmen and women in a context of less invasive treatment in the female group may seem odd. However, drug treatment adequacy, early diagnosis and distinct pathophysiology between the genders may help to explain this finding. 14 Nevertheless, in most studies, regardless of age, within 1 year after the first AMI, more women died when compared to men (26% vs. 19%), with similar results after 5 years (47% vs. 36%). 2,5,7,15 In one of the largest registries ever published on the subject, more than 2 million patients submitted to CABG were analyzed, comparing the prognosis between the genders. Unadjusted in-hospital mortality was higher in women (3.2% vs. 1.8%, p < 0.001). The female gender remained an independent predictor of mortality after the multivariate adjustment (OR = 1.40, 95%CI: 1.36-1.43, p < 0.001) in all age groups. However, an interesting result was the observation that in-hospital mortality declined at a faster rate in women (3.8% to 2.7%) than in men (2.2% to 1.6%) between 2003 and 2012. 15 Limitations Despite the large sample, this study is retrospective and has a much higher number of male patients in relation to the female group. Such differences are based on the actual incidence of ACS in the population and also on the failure to recognize the disease in women. Also, we do not have a description of the type of vascular access used, something that may influence the rate of bleeding associated with the percutaneous coronary intervention. Unusual manifestations of coronary disease, such as spasm or spontaneous dissection, were not described separately. The loss to follow-up of 7.3% of the patients may have influenced the results. Finally, patients with systemic diseases or neoplasias were not excluded, which could have influenced survival. Conclusion Multiple gender-related differences were observed in patients with acute coronary syndrome, regarding demographic characteristics, coronary artery disease pattern and implemented treatment. However, the in-hospital and medium-term prognostic evolution was similar between the groups. Author contributions Conception and design of the research: Soeiro AM, Silva PGMB, Roque EAC; Acquisition of data: Soeiro AM, Silva PGMB, Roque EAC, Biselli B, Leal TCAT, Soeiro MCFA; Analysis and interpretation of the data: Soeiro AM, Bossa AS, Biselli B, Leal TCAT, Soeiro MCFA; Statistical analysis: Soeiro AM; Writing of the manuscript: Soeiro AM, Pitta FG; Critical revision of the manuscript for intellectual content: Soeiro AM, Serrano Jr. CV, Oliveira Jr. MT. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This study was approved by the Ethics Committee of the CAPPesq under the protocol number 38511114.7.0000.0068. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 652