Risk-treatment paradox in women with symptomatic coronary artery disease

The implementation of evidence-based treatment including diagnostic and therapeutic invasive procedures has resulted in a reduction in the mortality attributable to coronary artery disease (CAD) despite the fact that patients at high risk are less likely to have access to it. Women in particular are up to 30 % less likely to receive percutaneous coronary intervention (PCI) following presentation with an acute coronary syndrome than men. This risk-treatment paradox for women is partially related to their older age, greater likelihood of comorbidities, and later presentation after symptom onset with more frequent atypical symptoms as well as to the higher proportion of symptomatic women having nonobstructive CAD. In addition, during the first decade of the PCI era, a poorer short-term survival after revascularization in women was reported while similar or better long-term outcomes than men was consistently observed. The subtly different spectrum of biological factors predisposing to high risk, frequent vascular complications, and high incidence of bleeding events, mostly related to the antithrombotic drugs over dosage, explain the early hazard seen in women. Newer antithrombotic regimens and the modern coronary stent platforms have contributed to drastic improvement of outcomes, particularly in high-risk subsets of patients including women. However, still more evidence from randomized trials with a representative proportion of women is required both to fully categorize CAD in women and to determine the most appropriate approach to therapy. Furthermore, physicians must continue to work to better identify high-risk patients and to tailor the evidence-based therapy to individual risk independent of patient’s sex.