Sex differences in cardiovascular outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Introduction

Cardiovascular disease (CVD) remains a leading cause of mortality globally, accounting for 30% to 45% of all deaths (1-4). Acute coronary syndrome (ACS) is a major contributor to CVD mortality, with reported in-hospital mortality rates ranging from 5% to 20% and 1-year mortality rates between 4% and 25% (5-9). Epidemiological data suggest that sex differences are associated with variations in clinical presentation, treatment response, and outcomes in patients with ACS (2,10).

Recent research has increasingly focused on sex-based differences in symptoms, treatment approaches, and outcomes in ACS patients, particularly those undergoing percutaneous coronary intervention (PCI) or fibrinolytic therapy. Multiple studies have shown that women experience significantly higher in-hospital mortality rates compared to men (3–10% vs. 2–4.5%) (11-13). However, findings on sex differences in 1-year mortality rates are inconsistent. Some studies reported significantly higher 1-year mortality rates in women than in men (15% vs. 7%) (12,14), whereas others found no significant difference (13).

In Asian populations, data on sex-influenced clinical outcomes in ACS patients are less extensively studied. Most studies demonstrated significantly higher in-hospital mortality rates among women (6–23%) compared to men (2–6%) (15-17). Conversely, one study reported no significant difference in in-hospital mortality rates (3.5% vs. 4.4%) and even lower 1-year mortality rates in women compared to men (15% vs. 22%) (18).

The observed discrepancies in findings may be attributed to differences in study populations, disease severity [e.g., non-ST elevation ACS (NSTE-ACS) vs. ST-elevation myocardial infarction (STEMI)], variations in standard treatment protocols over time, and regional disparities in healthcare quality. While sex differences in ACS outcomes have been extensively studied in Western and East Asian populations, data from Southeast Asia, particularly Thailand, remain limited. Given potential regional differences in healthcare access, treatment strategies, and patient demographics, contemporary data from this population are needed to inform clinical practice. This study aims to evaluate sex differences in cardiovascular outcomes among ACS patients undergoing PCI in the context of contemporary standard treatment guidelines. By addressing gaps in existing data, this study seeks to provide insights into these disparities within the Thai population, which remains underrepresented in the existing literature. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-100/rc).

Methods

This single-center, retrospective cohort study included patients aged 18 years or older with a diagnosis of ACS who underwent primary PCI at King Chulalongkorn Memorial Hospital between January 1, 2017, and October 31, 2021. The exclusion criteria were patients with a life expectancy of less than 1 year (e.g., advanced-stage cancer and end-stage liver disease), a follow-up period of less than 1 year, or were pregnant. Data were extracted from the hospital’s electronic database, including comorbidities, presenting symptoms, the severity of ACS (NSTE-ACS vs. STEMI), left ventricular ejection fraction (LVEF), coronary anatomy, mechanical complications (ventricular septal rupture, free wall rupture, and acute mitral regurgitation), complications, and mortality rates.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics committee of the Faculty of Medicine, Chulalongkorn University (IRB number 0696/65; certificate of full board approval number 1653/2022) and individual consent for this retrospective analysis was waived.

Outcomes

The primary outcomes of this study were in-hospital mortality and 1-year mortality. In-hospital mortality was defined as all-cause death occurring during the index hospitalization and was confirmed using hospital electronic medical records and discharge documentation. One-year mortality was defined as all-cause death occurring within 12 months following the index admission, based on hospital follow-up records. Patients who were lost to follow-up before 1 year were excluded from the study. Due to limitations in data availability, all-cause mortality was used as the outcome measure.

Secondary outcomes were post-procedural complications which include: (I) coronary artery complications (e.g., intramural hematoma, coronary perforation, and distal embolization); (II) vascular complications (e.g., access site bleeding, hematoma, arteriovenous fistula, and pseudoaneurysm); (III) acute kidney injury, defined as an increase in serum creatinine by ≥0.3 mg/dL within 48 hours or ≥1.5 times baseline within 7 days; (IV) stroke, defined as a new-onset neurological deficit confirmed by imaging; (V) bleeding; and (VI) nosocomial infection, defined as an infection acquired during hospitalization. Bleeding was classified as major and minor, as defined by the thrombolysis in myocardial infarction (TIMI) bleeding criteria. All secondary outcomes were recorded during the index hospitalization period from admission to discharge.

Two independent reviewers evaluated all outcomes with the third reviewer adjudicating when the results from the first two reviewers were discrepant. Outcomes were adjudicated based on hospital records, post-procedural blood tests, echocardiogram, related cardiovascular imaging, and civil registration.

Statistical analysis

Based on data from previous publications, the rates for women and men were estimated at 6.5% and 3% for in-hospital mortality (11-13) and 15% and 7% for 1-year mortality (12). Given a type I error of 5% (two-sided), and a power of 80%, the required sample size is 1,270 and 528 participants for in-hospital mortality and 1-year mortality, respectively.

Categorical data were presented as frequencies and percentages, while continuous data were expressed as mean ± standard deviation (SD) for normally distributed variables or median [interquartile range (IQR)] for non-normally distributed variables. Categorical data were compared using the Chi-squared test or Fisher’s exact test, and continuous data were analyzed using the independent t-test for normal distributions and the Mann-Whitney U test for non-normal distributions. The normality of data was determined by the Shapiro-Wilk test. Differences in 1-year mortality rates were evaluated using Cox proportional hazards models and survival analyses, with results expressed as hazard ratios (HRs) and 95% confidence intervals (CIs). Adjustments were made for pre-specified confounding variables including age >70 years, diabetes, hypertension, hyperlipidemia, chronic kidney disease, cardiogenic shock at the presentation, and LVEF <40%. Survival analysis was visualized using Kaplan-Meier curves. Statistical significance was defined as a P<0.05. Data analysis was performed using SPSS software version 29 (IBM Inc., Chicago, IL, USA).

Results

Baseline characteristics

Between January 1, 2017, and October 31, 2021, a total of 1,579 participants were enrolled after applying the exclusion criteria. Of these, 453 (28.7%) were women. Women were significantly older than men [median age: 70 (IQR, 60–79) vs. 60 (IQR 52–69) years, P<0.001] and had a higher prevalence of coronary artery disease (20.3% vs. 15.5%, P=0.02), atrial fibrillation (11.7% vs. 8.4%, P=0.044), diabetes (50.3% vs. 38.2%, P<0.001), and hypertension (74.2% vs. 55.1%, P<0.001).

Women were more likely to present with dyspnea (12.1% vs. 7.3%), whereas men more commonly presented with chest pain (80.8% vs. 86.2%). Women had a lower incidence of STEMI (50.8% vs. 62.8%; P<0.001), but a higher prevalence of heart failure (41.9% vs. 31.8%, P<0.001) and respiratory failure requiring invasive ventilation (14.8% vs. 10.2%, P=0.01). The incidence of cardiogenic shock requiring two or more inotropes, intra-aortic balloon pump (IABP) support, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) were not significantly different between the sexes. Detailed baseline characteristics are shown in Table 1.

The number of coronary artery involvements, culprit lesions, and mechanical complications are detailed in Tables S1,S2. No significant sex-based differences in coronary anatomy or mechanical complications were observed among patients with ACS undergoing PCI. The left anterior descending artery was the most common culprit lesion in both women (41.3%) and men (46.5%), followed by the right coronary artery (32.0% vs. 31.1%, respectively), with similar rates of single-, double-, and triple-vessel disease between sexes. Mechanical complications, including ventricular septal rupture, free wall rupture, and acute mitral regurgitation, were rare (0.2–0.4%) and showed no statistically significant differences between women and men.

Primary outcomes

The in-hospital mortality rate was higher in women but did not reach statistical significance (7.5% vs. 5.4%, P=0.12). However, the 1-year mortality rate was significantly higher in women compared to men (21.6% vs. 12.8%, P<0.001). Detailed clinical outcomes are presented in Table 2.

Cox proportional hazard model analysis for 1-year mortality revealed an HR of 1.75 (95% CI: 1.35–2.27; log-rank P<0.001) for women. After adjusting for pre-specified confounders, including age, diabetes, hypertension, hyperlipidemia, chronic kidney disease, cardiogenic shock, and LVEF, the adjusted HR was 1.46 (95% CI: 1.10–1.93; P=0.009). The Kaplan-Meier survival curve illustrating these differences is shown in Figure 1.

Figure 1 The Kaplan-Meier survival curves comparing 1-year mortality between men and women with ACS undergoing PCI. The log-rank test was used to compare survival distributions. ACS, acute coronary syndrome; PCI, percutaneous coronary intervention.

Landmark survival analysis at 3 months demonstrated that the difference in 1-year mortality between men and women remained significant beyond this period (Figure S1).

Given the high mortality risk associated with cardiogenic shock and mechanical circulatory support, we conducted an additional subgroup analysis showing 1-year mortality stratified by these factors. The results are summarized in Table S3. Of note, the proportion of patients with cardiogenic shock, IABP, VA-ECMO, or use of ≥2 inotropes was not significantly different between sexes.

Secondary outcomes

Post-procedural complications, including coronary artery complications, vascular complications, and stroke, were comparable between men and women. However, women experienced a higher incidence of acute kidney injury (20.5% vs. 15.5%, P=0.02), major bleeding events (1.8% vs. 0.4%, P=0.02), and nosocomial infections (17.0% vs. 8.5%, P<0.001) during the index hospitalization.

Discussion

This study demonstrated sex differences in baseline characteristics, clinical outcomes, and procedural complications in patients with ACS undergoing PCI at a tertiary care hospital. The findings underscore important disparities in presentation, comorbidities, and outcomes between women and men, contributing to a growing body of evidence that highlights sex as a critical factor influencing ACS management and prognosis.

Consistent with previous studies, women in this cohort were significantly older than men at the time of presentation and had a higher prevalence of comorbidities such as hypertension, diabetes, coronary artery disease, and atrial fibrillation (11). The proportion of women in this cohort was 28.7%, consistent with prior research (23–27%) (11-13,15). Women were also more likely to present with dyspnea and had lower rates of STEMI compared to men, reflecting established differences in symptom presentation and ACS subtype distribution. The higher prevalence of diabetes in women may explain the increased likelihood of presenting with dyspnea, as diabetes is associated with silent myocardial ischemia due to partial or complete autonomic denervation and microvascular dysfunction (19-21). Furthermore, diabetic women are more prone to left ventricular diastolic dysfunction, leading to elevated pulmonary pressures and pulmonary congestion, which manifests as dyspnea rather than chest pain (22-24). Notably, women in this study were more likely to present with dyspnea, which may indicate underlying heart failure or pulmonary congestion. Additionally, women had higher rates of heart failure and respiratory failure requiring invasive ventilation, reflecting greater disease severity during hospitalization.

Several factors, including differences in coronary plaque composition, hormonal influences, and vascular remodeling, may explain men’s higher incidence of STEMI. Men are more likely to develop rupture-prone plaques with a lipid-rich core and thin fibrous caps, leading to acute plaque rupture and complete coronary occlusion, a hallmark of STEMI (25-28). In contrast, women are more frequently affected by plaque erosion, which is more often associated with NSTE-ACS (29). Hormonal differences may also play a role; testosterone in men has pro-atherogenic effects that promote plaque instability, while estrogen in women offers vasoprotective effects that reduce inflammation and improve endothelial function, especially in premenopausal women (30-32). Furthermore, behavioral factors such as higher rates of smoking in men, a well-documented risk factor for STEMI, may further contribute to this disparity (33,34).

While in-hospital mortality was comparable between sexes, women had a significantly higher risk of long-term mortality. The lack of significant differences in in-hospital mortality contrasts with most previous studies (11-13,15,16), including the study by Srimahachota et al. [2004], which reported a significantly higher in-hospital mortality rate in women (23.1% vs. 6.1%, P=0.002) among patients undergoing primary PCI for STEMI at the same center (17). Their findings attributed this disparity to women being older, having a higher prevalence of diabetes, and more frequent presentations with cardiogenic shock, all of which are known predictors of mortality. However, in our study, standardized protocols, contemporary treatment advancements, and equitable access to care may have mitigated these sex-based differences during hospitalization. Additionally, the lower prevalence of STEMI in women in this cohort—a more severe ACS subtype strongly associated with in-hospital mortality—may have contributed to narrowing the gap between the sexes. Besides, a higher mortality rate than expected in men may cause the sample size to be underpowered to detect a smaller number of differences.

In contrast, the significantly higher 1-year mortality rate in women aligns with prior research and may be explained by their older age, greater burden of comorbidities such as diabetes and hypertension, and more severe clinical presentations, including higher rates of heart failure and respiratory failure (12,14). The Kaplan-Meier survival analysis revealed significant differences in survival probabilities between males and females. The survival analysis, which includes all participants, demonstrated a highly significant difference in survival between sexes (P<0.001), with males exhibiting better survival outcomes. In contrast, by excluding individuals who did not survive beyond 90 days, the Kaplan-Meier curve showed a reduced but still significant difference (P=0.03). These findings suggest that early mortality may play a crucial role in driving the overall survival differences observed in the full cohort. The diminished statistical significance after day 90 indicates that survival disparities between sexes become less pronounced over time. Further studies are warranted to explore the factors contributing to early mortality in females and to identify potential sex-specific interventions that could improve survival outcomes.

Women experienced higher rates of acute kidney injury (20.5% vs. 15.5%, P=0.02), major bleeding (1.8% vs. 0.4%, P=0.02), and nosocomial infections (17.0% vs. 8.5%, P<0.001) during the index hospitalization. These in-hospital complications may have contributed to the higher long-term mortality observed in women and could be considered intermediate factors along the causal pathway. These complications, compounded by biological differences such as smaller coronary artery size and greater microvascular dysfunction, may lead to worse long-term outcomes (35,36). After adjusting for confounders, the adjusted hazard ratio for 1-year mortality in women remained significantly elevated (HR: 1.46; 95% CI: 1.10–1.93), suggesting that sex itself may be an independent risk factor for poorer long-term outcomes.

Interestingly, post-procedural complications such as coronary artery complications, vascular complications, and stroke were comparable between sexes, suggesting that technical factors during PCI may not be the primary drivers of sex-based disparities in outcomes. Additionally, mechanical complications such as ventricular septal rupture, free wall rupture, and acute mitral regurgitation were rare and occurred at similar rates in both groups.

The results of this study emphasize the need for tailored strategies to improve outcomes in women with ACS. Addressing sex-based differences in risk factors, optimizing symptom recognition, and refining treatment protocols may help bridge the observed gaps in outcomes. Enhanced post-procedural care and early identification of complications such as acute kidney injury and bleeding are particularly important in this population.

This study has limitations that should be acknowledged. As with all retrospective observational studies, this analysis is subject to potential confounding and bias. Although we adjusted for several clinically relevant variables, the possibility of residual unmeasured confounders (e.g., socioeconomic status, time to treatment, and medication adherence) cannot be excluded. Furthermore, our study was conducted in a single tertiary-care center in Thailand, which may limit generalizability. Selection bias is also a potential limitation. Women with ACS are known to experience delays in diagnosis and treatment, which could lead to a selection of more severely ill female patients in our cohort. This is reflected in their higher prevalence of comorbidities and greater likelihood of presenting with heart failure and respiratory distress. Differences in symptom recognition and healthcare-seeking behavior may have further contributed to this imbalance, making it difficult to fully disentangle biological from healthcare-related factors influencing sex differences in outcomes. Additionally, the relatively low number of in-hospital deaths, particularly in subgroup analyses, may also limit statistical power. Mortality data were obtained from hospital medical records. As our database is not linked to the national death registry, only patients with complete 1-year follow-up data were included to ensure the accuracy of mortality outcomes. Cause-specific mortality could not be consistently retrieved and therefore was not analyzed.

Conclusions

Women with ACS undergoing PCI exhibit significant differences in baseline characteristics and clinical outcomes compared to men. Although in-hospital mortality rates were similar, women had higher long-term mortality and a greater incidence of post-procedural complications, including acute kidney injury, bleeding, and nosocomial infections. These disparities may be influenced by differences in comorbidities, symptom presentation, and procedural risk. Further research is needed to identify underlying mechanisms contributing to these outcomes and to determine whether targeted interventions may help mitigate sex-based differences in ACS prognosis.

Acknowledgments

The authors acknowledge the support for article processing from the Cardiac Center, King Chulalongkorn Memorial Hospital.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-100/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-100/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-100/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-100/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics committee of the Faculty of Medicine, Chulalongkorn University (IRB number 0696/65; certificate of full board approval number 1653/2022) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Haider A, Bengs S, Luu J, et al. Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. Eur Heart J 2020;41:1328-36. [Crossref] [PubMed]
2. Townsend N, Wilson L, Bhatnagar P, et al. Cardiovascular disease in Europe: epidemiological update 2016. Eur Heart J 2016;37:3232-45. [Crossref] [PubMed]
3. Dattani S, Spooner F, Ritchie H, et al. Causes of Death. Available online: https://ourworldindata.org/causes-of-death
4. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2024;403:2100-32. [Crossref] [PubMed]
5. Fanta K, Daba FB, Tegene E, et al. Management quality indicators and in-hospital mortality among acute coronary syndrome patients admitted to tertiary hospitals in Ethiopia: prospective observational study. BMC Emerg Med 2021;21:41. [Crossref] [PubMed]
6. Srimahachota S, Boonyaratavej S, Kanjanavanit R, et al. Thai Registry in Acute Coronary Syndrome (TRACS)--an extension of Thai Acute Coronary Syndrome registry (TACS) group: lower in-hospital but still high mortality at one-year. J Med Assoc Thai 2012;95:508-18.
7. Santos IS, Goulart AC, Brandão RM, et al. One-year Mortality after an Acute Coronary Event and its Clinical Predictors: The ERICO Study. Arq Bras Cardiol 2015;105:53-64. [Crossref] [PubMed]
8. Fanta K, Daba FB, Asefa ET, et al. Management and 30-Day Mortality of Acute Coronary Syndrome in a Resource-Limited Setting: Insight From Ethiopia. A Prospective Cohort Study. Front Cardiovasc Med 2021;8:707700. [Crossref] [PubMed]
9. Vervueren PL, Elbaz M, Wagner A, et al. The major element of 1-year prognosis in acute coronary syndromes is severity of initial clinical presentation: Results from the French MONICA registries. Arch Cardiovasc Dis 2012;105:478-88. [Crossref] [PubMed]
10. Rao U, Buchanan GL, Hoye A. Outcomes After Percutaneous Coronary Intervention in Women: Are There Differences When Compared with Men? Interv Cardiol 2019;14:70-5. [Crossref] [PubMed]
11. Yu J, Mehran R, Grinfeld L, et al. Sex-based differences in bleeding and long term adverse events after percutaneous coronary intervention for acute myocardial infarction: three year results from the HORIZONS-AMI trial. Catheter Cardiovasc Interv 2015;85:359-68. [Crossref] [PubMed]
12. Birkemeyer R, Schneider H, Rillig A, et al. Do gender differences in primary PCI mortality represent a different adherence to guideline recommended therapy? a multicenter observation. BMC Cardiovasc Disord 2014;14:71. [Crossref] [PubMed]
13. Al-Fiadh AH, Andrianopoulos N, Farouque O, et al. Contemporary outcomes in women undergoing percutaneous coronary intervention for acute coronary syndromes. Int J Cardiol 2011;151:195-9. [Crossref] [PubMed]
14. Earle NJ, Doughty RN, Devlin G, et al. Sex differences in outcomes after acute coronary syndrome vary with age: a New Zealand national study. Eur Heart J Acute Cardiovasc Care 2024;13:284-92. [Crossref] [PubMed]
15. Toyota T, Furukawa Y, Ehara N, et al. Sex-based differences in clinical practice and outcomes for Japanese patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. Circ J 2013;77:1508-17. [Crossref] [PubMed]
16. Zou Y, Zhu W, Zeng J, et al. Sex-differences in the management and clinical outcome among patients with acute coronary syndrome. BMC Cardiovasc Disord 2021;21:609. [Crossref] [PubMed]
17. Srimahachota S, Boonyaratavej S, Udayachalerm W, et al. Worse prognosis for women who underwent primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. J Med Assoc Thai 2004;87:519-24.
18. Tai S, Li X, Yang H, et al. Sex Differences in the Outcomes of Elderly Patients with Acute Coronary Syndrome. Cardiol Res Pract 2020;2020:5091490. [Crossref] [PubMed]
19. Tabibiazar R, Edelman SV. Silent ischemia in people with diabetes: a condition that must be heard. Clin Diabetes 2003;21:5-9.
20. Chiariello M, Indolfi C. Silent myocardial ischemia in patients with diabetes mellitus. Circulation 1996;93:2089-91. [Crossref] [PubMed]
21. Roy R, Aldiwani H, Darouian N, et al. Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS). Int J Cardiol 2020;316:1-6. [Crossref] [PubMed]
22. Nichols GA, Gullion CM, Koro CE, et al. The incidence of congestive heart failure in type 2 diabetes: an update. Diabetes Care 2004;27:1879-84. [Crossref] [PubMed]
23. Fontes-Carvalho R, Ladeiras-Lopes R, Bettencourt P, et al. Diastolic dysfunction in the diabetic continuum: association with insulin resistance, metabolic syndrome and type 2 diabetes. Cardiovasc Diabetol 2015;14:4. [Crossref] [PubMed]
24. Okura H, Inoue H, Tomon M, et al. Impaired glucose tolerance as a determinant of early deterioration of left ventricular diastolic function in middle-aged healthy subjects. Am J Cardiol 2000;85:790-2, A9.
25. Man JJ, Beckman JA, Jaffe IZ. Sex as a Biological Variable in Atherosclerosis. Circ Res 2020;126:1297-319. [Crossref] [PubMed]
26. de Bakker M, Timmerman N, van Koeverden ID, et al. The age- and sex-specific composition of atherosclerotic plaques in vascular surgery patients. Atherosclerosis 2020;310:1-10. [Crossref] [PubMed]
27. Kerkhof PLM, Tona F. Sex differences in diagnostic modalities of atherosclerosis in the macrocirculation. Atherosclerosis 2023;384:117275. [Crossref] [PubMed]
28. van Dam-Nolen DHK, van Egmond NCM, Koudstaal PJ, et al. Sex Differences in Carotid Atherosclerosis: A Systematic Review and Meta-Analysis. Stroke 2023;54:315-26. [Crossref] [PubMed]
29. Yahagi K, Davis HR, Arbustini E, et al. Sex differences in coronary artery disease: pathological observations. Atherosclerosis 2015;239:260-7. [Crossref] [PubMed]
30. Kwapong YA, Sharma G, Valero-Elizondo J, et al. The association of sex-specific hormones with coronary artery plaque characteristics from Miami Heart (MiHeart) study. Am J Prev Cardiol 2023;14:100479. [Crossref] [PubMed]
31. Harris K, Peters SAE, Woodward M. Sex hormones and the risk of myocardial infarction in women and men: a prospective cohort study in the UK Biobank. Biol Sex Differ 2023;14:61. [Crossref] [PubMed]
32. Zhao D, Guallar E, Ouyang P, et al. Endogenous Sex Hormones and Incident Cardiovascular Disease in Post-Menopausal Women. J Am Coll Cardiol 2018;71:2555-66. [Crossref] [PubMed]
33. Redfors B, Furer A, Selker HP, et al. Effect of Smoking on Outcomes of Primary PCI in Patients With STEMI. J Am Coll Cardiol 2020;75:1743-54. [Crossref] [PubMed]
34. Larsen GK, Seth M, Gurm HS. The ongoing importance of smoking as a powerful risk factor for ST-segment elevation myocardial infarction in young patients. JAMA Intern Med 2013;173:1261-2. [Crossref] [PubMed]
35. Hiteshi AK, Li D, Gao Y, et al. Gender differences in coronary artery diameter are not related to body habitus or left ventricular mass. Clin Cardiol 2014;37:605-9. [Crossref] [PubMed]
36. Wentzel JJ, Papafaklis MI, Antoniadis AP, et al. Sex-related differences in plaque characteristics and endothelial shear stress related plaque-progression in human coronary arteries. Atherosclerosis 2022;342:9-18. [Crossref] [PubMed]