Quick Dive: Antithrombotic drugs for acute coronary syndromes in women

What is the reason for and aim of the publication?

The publication aims to offer expert, evidence-based guidance on tailoring antithrombotic therapy for women with acute coronary syndromes (ACS), recognising their distinct ischemic and bleeding risk profiles. It seeks to raise awareness of sex-specific risks and potential biases in ACS management, with particular emphasis on bleeding mitigation strategies, antithrombotic use in special clinical scenarios such as myocardial infarction with non-obstructive coronary arteries (MINOCA), and the persistent under-representation of women in cardiovascular trials. By providing consensus statements informed by the best available evidence, the manuscript strives to optimise sex-specific antithrombotic management and reduce disparities in outcomes between women and men.

What are the most important take-home messages?

1. Individualise dosing and access strategy – women have a higher bleeding risk; adjust antithrombotic doses for weight, renal function, and age, use bleeding risk scores, and favour radial over femoral access to minimise complications.
2. Tailor therapy to clinical context — apply sex-specific considerations in ACS subtypes (e.g., SCAD, MINOCA, vasospastic/microvascular angina, Takotsubo), and in special situations such as pregnancy, with cautious selection and monitoring of agents.
3. Close the evidence gap by improving female representation in clinical trials.

What are challenges in practical implementation – and possible solutions?

• Physician awareness gap and unconscious bias → implement targeted education and training programmes to improve recognition of sex-specific ACS presentations and risks.
• Under-representation of women in trials → mandate prespecified enrollment targets, broaden eligibility criteria, and design women-specific or pregnancy-conscious studies.
• Logistical barriers to trial participation (e.g., travel, caregiving responsibilities) → offer remote monitoring options, flexible scheduling, and logistical or financial support.
• Referral and enrollment gaps → involve primary care physicians and family members early in the trial screening process, and use community engagement to improve trust and participation.
• Better assessment of baseline bleeding risk in women → standardise weight- and renal-adjusted dosing protocols, embed bleeding risk scoring in clinical workflows, and promote radial access as default.
  

Which issues still need to be tackled, that are not yet addressed by the paper?

• High-quality RCT data tailored to SCAD, MINOCA, vasospastic/microvascular angina, and TTS.
• Optimal antithrombotic choices and dosing during pregnancy and lactation across ACS scenarios.
• Clearer evidence for sex-specific thresholds within bleeding/ischemic risk scores used to guide duration/intensity.
  

What further developments on the topic are emerging?

• Trial design goals: prespecified sex-stratified randomization/enrollment targets; transparent sex-specific efficacy/safety reporting.
• Access and dosing quality programmes embedding weight/renal-based dosing and radial-first pathways.
• Novel agents/approaches and precision dosing that may reduce bleeding while preserving efficacy (e.g., better monitoring frameworks in pregnancy and low-weight patients
  

Clinical consensus statement: Antithrombotic drugs for acute coronary syndromes in women

Valeria Paradies, Giulia Masiero, Andrea Rubboli et al. Antithrombotic drugs for acute coronary syndromes in women: sex-adjusted treatment and female representation in randomised clinical trials. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the ESC Working Group on Thrombosis. European Heart Journal, Volume 46, Issue 28, 21 July 2025, Pages 2730–2741, https://doi.org/10.1093/eurheartj/ehaf352

Document types published by the ESC, Associations, Councils, Working Groups, and ESC Committees (according to the ESC Scientific Documents Policy):