An increased risk of recurrent acute coronary syndrome (ACS) was seen in younger adults with ACS with feminine gender, according to new research published in the Journal of the American College of Cardiology.

The GENESIS-PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond-Premature Acute Coronary Syndrome) investigators studied 273 women and 636 men aged 18 to 55 years between January 2009 and April 2013. They assessed gender-related characteristics (eg, social roles) via a self-administered questionnaire and derived a composite measure of gender.

The questionnaire identified 7 variables that were independently associated with biological sex and included in the gender-related score: status of household primary earner, personal income, number of hours per week spent doing housework, status of primary person responsible for doing housework, stress level at home, Bem Sex Role Inventory masculinity score, and Bem Sex Role Inventory femininity score. A lower score indicated the patient was more likely to be a man (teritle 1) and a higher score indicated the patient to be a woman (tertile 3).

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Recurrent ACS served as the primary outcome, and major adverse cardiac events (MACE) and all-cause mortality over 12 months served as secondary outcomes.

At 12 months, the proportions of men and women with recurrent ACS, MACE, and all-cause mortality were similar (3% for ACS; 8% for MACE; <1% for all-cause mortality). However, when patients were categorized according to the tertiles of gender-related scores, recurrent ACS rates in patients “with characteristics traditionally ascribed to women was 5% compared with 2% in the other 2 groups.”

After multivariable adjustments, the difference between feminine roles/personality traits and masculine characteristics persisted (hazard ratio [HR]: 4.50; 95% confidence interval [CI]: 1.05-19.28; P=.04).

Furthermore, in patients in tertiles 3 and 2 of the gender-related score, the rate of MACE was 9%, compared to 6% in teritle 1 patients. Patients with characteristics traditionally ascribed to women were more likely to experience a MACE compared to patients with characteristics traditionally ascribed to men (HR: 1.54; 95% CI: 0.90-2.66; P=.12).

In tertile 3 specifically, patients were more likely to be unmarried, smoke, have high levels of anxiety and depression, diabetes, hypertension, family history of CVD, and prior CV events before the index ACS than patients in the other tertiles.

Higher levels of anxiety decreased the effect size of gender-related score by >10%, and thus rendered its association with recurrent ACS nonstatistically significant. Researchers observed, “This result indicates that elevated anxiety may be a pathway through which personality traits and social roles traditional ascribed to women increase the risk of recurrent ACS.”

“Further studies in larger cohorts are needed to confirm these findings and explore the mechanisms responsible for the associations between feminine gender scores and adverse cardiovascular events,” they concluded.


Pelletier R, Khan NA, Cox J, et al; for the GENESIS-PRAXY Investigators. Sex vs gender-related characteristics. Which predicts outcome after acute coronary syndrome in the young? J Am Coll Cardiol. 2016;67(2):127-135. doi:10.1016/j.jacc.2015.10.067.