Sex-Based Differences in Clinical Presentation, Management, and Outcomes of Acute Coronary Syndrome in Brazilian Emergency Medical Services
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Background
Sex-related disparities in acute coronary syndrome (ACS) recognition and management remain an important global health concern. Women frequently present with less common symptoms and may experience delays in diagnostic evaluation. This study examined sex-based differences in clinical presentation, management, and outcomes among patients with acute chest pain attended by emergency medical services (EMS) across Brazil.
Methods
We conducted a retrospective multicenter study using a national registry database from 14 Brazilian states between January 2020 and June 2024, within a large private hospital network. All patients presenting with acute chest pain were classified by trained cardiologists as unstable angina (UA), ST-elevation myocardial infarction (STEMI), or non–ST-elevation myocardial infarction (NSTEMI). Multivariable regression models, with men as the reference group, evaluated sex differences in diagnosis, treatment, and outcomes; categorical outcomes were modeled with logistic or multinomial logistic regression and continuous outcomes with linear regression. Sensitivity analyses included state-clustered standard errors and E-value quantification of potential unmeasured confounding.
Results
Among 7,171 patients with confirmed ACS (68.2% male), the median age was 63.0 years [IQR 20.0]; women were older than men (67.0 [20.0] vs 61.0 [19.0] years). Final diagnoses were UA in 46.7%, STEMI in 18.8%, and NSTEMI in 34.6% of patients. Men accounted for 75.5% of STEMI and 69.7% of NSTEMI cases. Overall, 91.7% received aspirin and 89.6% received at least one additional antiplatelet agent. After multivariable adjustment, women had higher odds of chest pain classified as probably ischemic and possibly ischemic compared with definitely ischemic chest pain (adjusted OR 1.51 [95% CI 1.33–1.72] and 1.60 [1.37–1.86], respectively) and lower odds of STEMI and NSTEMI relative to unstable angina (adjusted OR 0.59 [0.51–0.68] and 0.74 [0.66–0.83], respectively). Door-to-ECG time was longer in women in the unadjusted analysis (β=1.53 minutes [0.24–2.82]) but the difference was no longer significant after adjustment (β=1.04 minutes [−0.27 to 2.36]). In-hospital mortality did not differ between sexes in unadjusted analysis, and there was no evidence of excess short-term mortality in women.
Conclusions
Within a large private hospital network in Brazil, women with confirmed ACS were more often classified with less definitely ischemic type of chest pain and were less frequently classified as STEMI or NSTEMI than men. Differences in door-to-ECG time did not persist after adjustment, and in-hospital mortality did not differ by sex. These findings highlight the relevance of sex-sensitive triage and diagnostic protocols within EMS systems to reduce inequities in ACS recognition and treatment.
