Sex-specific differences in acute coronary syndrome management and outcomes: How age and treatment gaps mask a female survival advantage.

BACKGROUND AND AIMS: This nationwide registry study examined sex-specific differences in acute coronary syndrome management and all-cause mortality in Hungary between 2014 and 2024. METHODS: Data from 184,616 patients in the Hungarian National Myocardial Infarction Register were analyzed. Median follow-up was 3.1 years (interquartile range: 0.8-6.2 years). Mortality was assessed using univariable and multivariable methods, Cox regression, Kaplan-Meier analysis, and propensity score matching for age, acute coronary syndrome subtype, revascularization status, and diabetes mellitus, yielding 141,342 matched individuals. RESULTS: Female patients were older and had higher rates of diabetes and hypertension, whereas males more often received timely percutaneous coronary intervention and guideline-recommended therapies. Unadjusted mortality was higher among females (1-year mortality: 25.7% vs. 19.8%). After matching, however, females showed a 10.3 percentage-point lower all-cause mortality than males (p < 0.001). This association varied by age and acute coronary syndrome subtype: it was strongest in younger and middle-aged patients and those with NSTEMI, attenuated among patients aged ≥75 years, and reversed among patients with STEMI. CONCLUSIONS: Although females present with more complex clinical profiles and receive less intensive treatment, the observed association between sex and mortality changed substantially and heterogeneously after adjustment for measured baseline differences, varying by age and acute coronary syndrome subtype. These findings highlight the importance of addressing sex-based disparities in acute coronary syndrome care and ensuring equitable access to diagnosis, guideline-recommended therapies, and revascularization.