Women and acute coronary syndromes: still up to no good

Almost three decades ago, Dr Bernadine Healy first described the ‘Yentl Syndrome’ named after the Jewish heroine in Isaac Bashevis Singer’s short story who decides to dress and act like a man so that she can be educated in the Talmud philosophy. The ‘Yentl Syndrome’ has drawn our attention to cardiovascular healthcare inequality between males and females and has prompted the deeper investigation of coronary artery disease (CAD) in women. As a result, substantial progress has been made in improving the awareness of cardiovascular disease as the major cause of morbidity and mortality in women. Accordingly, while earlier work signalled a female propensity towards worse outcomes following acute coronary syndrome (ACS), contemporary reports indicate that this gender gap is gradually closing. The latter has been attributed to better access to revascularization therapies and to application of guideline-directed therapies for both sexes. However, despite recent improvements, significant gender/sex-related disparities persist and CAD mortality in women remains substantial. Most intriguingly, there seems to be stagnation in the improvements of CAD incidence and mortality in younger females since studies show consistently poorer outcomes in this subgroup of patients. The degree to which this disparity is explained by baseline cardiovascular characteristics, treatment patterns, or response to treatment remains an area of debate. In this issue of the journal, Gabet et al. now provide additional evidence for these alarming tendencies by reporting a significant increase in ACS hospitalizations in females aged <65 years, with the most pronounced rise seen in young women aged 45–54 years admitted for ST-elevation myocardial infarction (STEMI). The authors investigated recent trends in the annual incidence of ACS in France and analysed hospitalization data between 2004 and 2014. In contrast to their observations in younger females, the authors found a significant reduction in ACS admission rates for elderly women and men. In-hospital mortality was higher in women than in men, and this mortality gap between sexes was most pronounced in patients admitted for STEMI. Importantly, these trends resulted in a significant decrease of mean age at ACS admission in women but not in men during the study period. While these data are unique in that they provide us with changes in ACS incidence over time in a large population, they raise one important question: what are the reasons for these unfavorable findings in young women? By referring to recent data, the authors speculate that the increasing prevalence of obesity and smoking amongst women might be responsible for the observed rise in ACS cases in young females. However, while the epidemic increase in obesity is indeed particularly pronounced in young women, recent work indicates that non-traditional risk conditions such as socio-economic and psychosocial factors may contribute substantially to the increasing risk noticed in this younger population. Indeed, depression and perceived stress are much more common in younger women as compared with young men and have been shown to increase the risk of CAD. This trend is not surprising, given that psychosocial stress has substantially increased for women during the last two decades due to a continuous increase in women’s economic participation and educational attainment. Further, low socio-economic status is an established variable inversely associated with global coronary risk and imposes a higher excess risk on women as compared with men. According to the 2016 periodic report of Secours Catholique Caritas France, women are amongst those that have been hit hardest by the global economics crisis. In fact, in 2016, a total of 57% of poor adults living in France were women, as compared with 50% in 2001. This escalation was also explained by the greater number of single-parent households, with women leading single-parent families in overwhelming numbers. Thus, the current feminization of poverty, together with the higher vulnerability of women to the detrimental associations of social disadvantage and cardiovascular risk, might represent a considerable cardiovascular risk condition. Nevertheless, sex-related cardiovascular risk factors such as polycystic ovary syndrome, premature menopause, or a history of pre-eclampsia as well as traditional risk