Sex-based differences in acute coronary syndrome: mechanisms, management, and outcomes.

INTRODUCTION: Acute coronary syndrome (ACS) remains a leading cause of morbidity and mortality worldwide. Sex- and gender-related differences in ACS persist and encompass risk profiles, clinical presentation, management, and outcomes. AREAS COVERED: PubMed was searched from database inception through May 2026 for relevant literature on sex- and gender-based differences in ACS. This review examines these differences across the entire continuum of ACS, including cardiovascular risk factors, symptom presentation, underlying pathophysiological mechanisms, in-hospital management, secondary prevention, and long-term outcomes. EXPERT OPINION: Sex-related disparities in ACS reflect a complex interplay between biological factors, comorbidities, and modifiable gaps in care. However, adjusted outcomes are not uniformly worse in women and vary across cohorts, with some registry data suggesting less favorable outcomes in older men. Improved recognition of sex-related differences and more consistent implementation of evidence-based care are needed across the ACS continuum. Such efforts are essential to improve outcomes for both women and men.