Coronary Artery Disease

Marianne Hartford, MD, PhD, and Annica Ravn-Fischer, MD, PhD, on How Gender Affects ACS Outcomes

How gender affects outcomes and predictors of acute coronary syndrome (ACS) continues to be debated. However, a new study led by Marianne Hartford, MD, PhD, and Annica Ravn-Fischer, MD, PhD, assessed the long-term mortality associated with ACS and how baseline variables affected men vs women.1

Cardiology Consultant caught up with Drs Hartford and Ravn-Fischer to gain more insights to their research.

Marianne Hartford, MD, PhD, is faculty in the Department of Molecular and Clinical Medicine in the Sahlgrenska Academy at the University of Gothenburg in Gothenburg, Sweden.

Annica Ravn-Fischer, MD, PhD, is a physician specializing in acute coronary syndromes at Sahlgrenska University Hospital in Gothenburg, Sweden.

CARDIOLOGY CONSULTANT: How did your study come about? Why is studying ACS between the genders an important issue?

Marianne Hartford and Annica Ravn-Fischer: In the early 1990s, several large-scale studies reported marked differences in presentation, treatment, and outcomes between women and men with ACS. There seemed to be a widespread conception that women with ACS fare much worse than men. We wanted to investigate the long-term outcomes after ACS from a gender aspect in order to identify potential areas for improvement in both genders, but women in particular.

CARDIO CON: After analyzing the data, what conclusions did you and your team come to?

MH, ARF: We found no support for the perception that women with ACS have a worse long-term outcome than men of similar age. Admittedly, our unadjusted figures showed some increase in risk of death in women, but after adjusting for age, this disadvantage disappeared and actually turned to an advantage for women. Several of the well-recognized factors related to the risk of death in patients with ACS had a similar impact on outcome in women and men, but we also found some dissimilarities. For instance, treatment with psychotropic drugs at discharge was significantly associated with increased long-term mortality in men only.

CARDIO CON: How might these conclusions impact clinical practice or how ACS is managed between the genders?

MH, ARF: Our results, with respect to outcome, was gratifying since this would mean that women are not as badly treated and so neglected and misunderstood as repeatedly suggested during recent years. However, the impact on clinical practice must involve further efforts to increase our knowledge of heart disease in women. It may not be optimal to use exactly the same treatment strategies in women as in men. Our goal must be a personalized and tailored treatment, but until we know more, the same guideline-recommended therapy should be instituted in both women and men.

CARDIO CON: What gender-specific strategies might help improve long-term survival rates?

MH, ARF: Previous reports have demonstrated greater prevalence of hypertension and secondary development of heart failure with preserved ejection fraction in women. Modern treatment of hypertension seems to be less-often used in women than in men. Therefore, more focus should probably be spent on blood pressure lowering in women.

CARDIO CON: What is the key take-home message for practicing cardiologists?

MH, ARF: Coronary artery disease is the leading cause of death in both genders. Make sure to follow current guidelines for secondary prevention in both women and men. In particular, ensure that blood pressure is properly controlled and that any sign of heart failure is taken care of immediately. Make a special effort to identify and control risk factors in patients with mental health or psychiatric disorders.


  1. Ravn-Fischer A, Perers E, Karlsson T, Caidahl K, Hartford M. Seventeen-year mortality following the acute coronary syndrome: gender-specific baseline variables and impact on outcome. Cardiology. 2019;143:22-31.