Gender differences in the management and outcomes of acute coronary syndrome in indians: A systematic review and meta-analysis

Background: Gender differences in acute coronary syndrome (ACS) outcomes have been noted in global data, which however did not analyse Indian data. No prior systematic review and meta-analysis (SRM) has addressed this important aspect of gender bias in Indian women with ACS. Hence this SRM aimed to address this knowledge gap.

Methods: Electronic databases were searched for studies in ACS comparing cardiovascular disease presentation, treatment received and outcomes in women and men from India. Primary outcomes were to evaluate gender-differences in 30-day death and major adverse cardiovascular events (MACE). Secondary outcomes were to evaluate gender-differences in presentation, management and mortality. The SRM is registered with PROSPERO (CRD42023477286).

Results: From initially screened 3753 articles, data from 9 studies (61,185 patients) were analysed. Women with ACS had higher prevalence of diabetes [Odds ratio (OR) 1.65(95%CI:1.33-2.04); p < 0.001; I² = 95 %] and hypertension [OR2.06(95%CI:1.88-2.25); p < 0.001; I² = 42 %]. Smoking was significantly lower in women [OR 0.05(95%CI:0.03-0.07); p < 0.001; I² = 87 %]. Non-ST elevation myocardial infarction (NSTEMI) was significantly higher in women [OR 1.92(95%CI:1.66-2.21); p < 0.001; I² = 0 %]. Diagnostic angiography [OR 0.64(95%CI:0.56-0.74); p < 0.001; I² = 46 %] and percutaneous coronary interventions [OR0.71(95%CI:0.55-0.92); p = 0.01; I² = 92 %] were significantly lower in women. Women had significantly higher 30-day mortality [Hazard ratio (HR)2.26(95%CI:2.01-2.55); p < 0.001; I² = 6 %], 1-year mortality [HR2.41(95%CI:1.89-3.07); p < 0.001; I² = 53 %], in-hospital death [HR1.88(95%CI:1.19-2.96); p = 0.007; I² = 92 %], stroke [HR 1.84 (95%CI:1.34-2.52); p < 0.001; I² = 0 %] and MACE outcomes [OR 2.05 (95%CI:1.78-2.35); p < 0.001]. Use of aspirin, clopidogrel, beta-blockers and nitrates were significantly lower in women.

Conclusion: Our study highlights worse outcomes in Indian women with ACS. Higher burden of diabetes and hypertension, decreased used of PCI and lesser aggressive pharmacotherapy may be some of the contributing factors.