Sex differences in distribution, management and outcomes of combined ischemic-bleeding risk following acute coronary syndrome.
BACKGROUND
Risk factors for further bleeding and ischemic events after acute coronary syndrome (ACS) often overlap. Little is known about sex-based differences in the management and outcomes of ACS patients according to their combined bleeding-ischemic risk.


METHODS
All ACS hospitalizations in the United Kingdom (2010-2017) were retrospectively analyzed, stratified by sex and bleeding-ischemic risk combination (using CRUSADE and GRACE scores). Multivariable logistic regression was performed to examine association between risk-groups and 1) receipt of guideline-recommended management and 2) in-hospital outcomes.


RESULTS
Of 584,360 patients, a third of males (32.3%) and females (32.6%) were in the dual high-risk group (High CRUSADE- High GRACE). In comparison to the dual low-risk group (Low CRUSADE-Low GRACE), the dual high-risk patients of both sexes were 59-83% less likely to receive inpatient revascularisation (PCI or CABG) and 50% less likely to receive dual antiplatelet therapy (DAPT) on discharge, with a significant increase in odds of MACE (~8 to 9-fold), all-cause and cardiac mortality (25 to 35-fold), and bleeding (78-91%). The greatest difference in management and clinical outcomes between sexes was found in the dual-high risk group where females were less likely to receive guideline-recommended therapy (revascularisation and DAPT), compared to males, and were more likely to experience MACE, all-cause and cardiac mortality.


CONCLUSION
ACS patients with dual high-risk for bleeding and recurrent ischemia, especially females, are less likely to receive guideline-recommended therapy and experience significantly worse outcomes. Novel strategies are needed to effectively manage this highly prevalent, complex patient group and address the under-treatment of females.
['Mohamed|Mohamed O|MO|', 'Rashid|Muhammad|M|', 'Timmis|Adam|A|', 'Clarke|Sarah|S|', 'Lawson|Claire|C|', 'Michos|Erin D|ED|', 'Kwok|Chun Shing|CS|', 'De Belder|Mark|M|', 'Valgimigli|Marco|M|', 'Mamas|Mamas A|MA|']
D054058:Acute Coronary Syndrome D005260:Female D006801:Humans D007511:Ischemia D008297:Male D062645:Percutaneous Coronary Intervention D010975:Platelet Aggregation Inhibitors D012189:Retrospective Studies D018570:Risk Assessment D012727:Sex Characteristics D016896:Treatment Outcome D006113:United Kingdom
Sex Management Outcomes CRUSADE GRACE Risk scores