Gender Disparities in Acute Coronary Syndrome among Young Indians: A Call for Equity

REDEFINING CARDIOVASCULAR DISEASE: NOT JUST A MAN’S PROBLEM

Heart disease is the primary cause of death among women in India, accounting for nearly 18% of all female deaths. This surpasses the mortality rates from breast cancer and all other cancers combined.^[1]

Over the past two decades, the prevalence of heart disease among Indian women has increased by nearly 300%.^[2] This surge is attributed to factors such as lifestyle changes, increased stress levels, and a rise in risk factors such as high blood pressure, high cholesterol, obesity, and diabetes.

Alarmingly, studies indicate that Indian women face a 25% higher risk of developing heart diseases compared to men.

However, prevailing perceptions that cardiovascular disease (CVD) is primarily a male problem have led to delays in diagnosis and treatment. Women more often present with atypical symptoms – such as dyspnea, fatigue shortness of breath, or nausea, rather than classic chest pain, which often leads to misdiagnosis or underdiagnosis.^[3]

RISK FACTORS: SAME LABELS, DIFFERENT BURDENS

Although the traditional risk factors, namely hypertension, hyperlipidemia, diabetes, physical inactivity, poor diet, and family history remain similar for both genders, women experience a disproportionately higher risk of cardiac events compared to men.^[3,4]

Women, especially younger ones, face unique risk-enhancing conditions including premature ovarian failure, gestational diabetes, pre-eclampsia, polycystic ovary syndrome, early menarche, early menopause, adverse pregnancy outcomes, and hormonal contraceptive use.^[5]Unfortunately, these gender-specific risks remain underrepresented in clinical practice and are rarely incorporated into standard risk-scoring algorithms. These gender-specific risk factors necessitate a more tailored approach to cardiovascular risk assessment and prevention.

Epidemiological data also reveal a worrying trend: from 2000 to 2015, women in India showed greater increases in body mass index, tobacco use, diabetes, and periodontal infections compared to men.^[6] This highlights a growing cardiometabolic burden among Indian women.

Sex-based biological differences also play a crucial role. Women typically have higher myocardial blood flow and experience more shear stress, predisposing them to coronary artery disease. Hormonal differences may also affect vascular stiffness and disease presentation. Unlike men, women often present with diffuse, non-obstructive plaques, and lower overall plaque burden. They are also more likely to experience myocardial infarction with non-obstructive coronary arteries, spontaneous coronary artery dissection, or microvascular angina.^[7] These conditions may not be detected by conventional diagnostic approaches focused on obstructive plaques.

STRUCTURAL AND CULTURAL BARRIERS TO CARE

Women’s cardiovascular health is not only shaped by biological differences but also by structural inequities. Gender intersects with socioeconomic status, geography, and education – compounding disparities in healthcare access.^[8] In India, caregiving responsibilities, social stigma, and financial dependence often delay women’s care-seeking behavior. Even when they do seek care, unconscious biases among healthcare providers may contribute to the underestimation or dismissal of cardiac symptoms.

Evidence suggests that women are less likely to receive guideline-directed medical therapy, less frequently referred for revascularization or cardiac rehabilitation, and undergo fewer interventional procedures compared to men.^[9] A national survey reported that although the prevalence of heart disease is similar among men and women (7/1,000), 2.6% of women went untreated compared to 1.4% of men.^[10]

INSIGHTS FROM STUDY

The study analyzing 550 young Indian ACS patients provides a valuable yet sobering look at gender disparities.^[11] Although women made up only 10% of the cohort – a limitation reflecting broader underrepresentation in research – the findings were telling. Women had a higher prevalence of obesity (56.9% vs. 38.7% in men), reinforcing growing concerns over metabolic health in young Indian females. Despite this, they exhibited lower rates of multivessel disease and more frequently had normal coronary arteries, pointing toward alternative, non-atherosclerotic mechanisms like vasospasm. Men had more extensive multivessel disease and lower left ventricular ejection fraction, a likely reflection of more aggressive atherosclerotic disease tied to smoking and metabolic derangements. A striking finding was the disparity in treatment: Percutaneous coronary intervention was performed in just 43.1% of women, compared to 60.9% of men. While some of this difference may be attributed to angiographic findings, it raises the specter of systemic under-treatment – a concern echoed in global literature.

The study has certain limitations such as exclusion of female-specific risk factors, lack of family history data, absence of ACS classification, and short follow-up duration. These omissions restrict a full understanding of gendered differences in disease presentation and prognosis. The study’s retrospective, single-center design and underrepresentation of women further challenge its generalizability.

A GENDER-RESPONSIVE ROADMAP

Transforming ACS care in India requires a shift from gender neutrality to gender responsiveness. This involves:

• Integrating female-specific risk factors into clinical risk assessments and national guidelines

• Training healthcare professionals to recognize atypical presentations and minimize diagnostic delays

• Boosting representation of women in cardiovascular research to generate sex-specific data

• Designing tailored public health strategies, such as emphasizing metabolic syndrome control in women while targeting smoking cessation in men

• Strengthening healthcare access for women through policy initiatives, community engagement, and inclusion in national programs.

CONCLUSION

As India confronts an epidemic of premature heart disease, closing the gender gap in ACS outcomes is not only a public health priority but also a moral necessity. The findings of Mahorkar et al. and a growing body of evidence underscore the urgent need for systemic change in research, clinical care, and policy. Equity in cardiovascular health cannot be achieved until women are fully recognized, accurately diagnosed, and adequately treated.