Acute Coronary Syndrome In Women Research Articles

Spontaneous Coronary Artery Dissection in a Male Patient With Fibromuscular Dysplasia

Abstract A male patient presented with cardiac arrest attributed to anterior ST-segment elevation myocardial infarction from type 1 spontaneous coronary artery dissection. Subsequent imaging confirmed fibromuscular dysplasia in noncoronary arterial segments. The patient was started on guideline-directed medical therapy and referred to cardiac rehabilitation, showing substantial improvements in clinical status. With greater awareness and advancements in imaging, spontaneous coronary artery dissection has been more frequently recognized, and although as many as 81% to 92% of all cases occur in female patients, it can be seen among men, as well. Adjunctive imaging for arteriopathies may help establish the diagnosis for equivocal causes of acute coronary syndrome in women and men.

Acute Coronary Syndrome in Women: An Update.

The goal of this manuscript is to provide a concise summary of recent developments in the approach to and treatment of women with acute coronary syndrome (ACS). This review covers terminology updates relating to ACS and myocardial injury and infarction. Updates on disparities in recognition, treatments, and outcomes of women with ACS due to atherosclerotic coronary artery disease are covered. Other causes of ACS, including spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary artery disease are discussed, given the increased frequency in women compared with men. The review summarizes the latest on the unique circumstance of ACS in women who are pregnant or post-partum, including etiologies, diagnostic approaches, medication safety, and revascularization considerations. Compared with men, women with ACS have unique risk factors, presentations, and pathophysiology. Treatments known to be effective for men with atherosclerosis-related ACS are also effective for women; further work remains on reducing the disparities in diagnosis and treatment. Implementation of multimodality imaging will improve diagnostic accuracy and allow for targeted medical therapy in the setting of myocardial infarction with non-obstructive coronary artery disease.

Histological and functional assessment of a Takotsubo cardiomyopathy model established by immobilization stress.

Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, resembles acute heart failure syndrome but lacks disease-specific diagnosis and treatment strategies. TTC accounts for approximately 5-6% of all suspected cases of acute coronary syndrome in women. At present, animal models of TTC are often created by large amounts of exogenous catecholamines such as isoproterenol. However, isoproterenol injection cannot fully simulate the onset of stress-induced cardiomyopathy in humans since stress is not an instantaneous event. Rats were immobilized for 6h per day for 1-14 days. To examine whether the TTC model was successful, echocardiography was employed; Elisa detected serum sympathetic activation markers; and the Open-Field test (OFT) was used to analyze behavioral changes in rats after stress. Western blot and histology were used to assess sympathetic remodeling, inflammation levels, and fibrosis; qRT-PCR was used to explore the levels of fibrosis and myocardial hypertrophy. The electrical stability of ventricular was determined by electrophysiological testing. The rats showed severe stress behavior and local sympathetic remodeling of the heart after only 1 day of stress. After 3 days of stress, the induction of ventricular tachyarrhythmia increased prominently. The highest incidence of TTC in rats was at 5 days of immobilization stress. The pathological left ventricular remodeling caused by immobilization (IMO) stress includes inflammatory infiltration, fibrosis, and myocardial hypertrophy. Our study confirms the hypothesis that IMO stress can mimic Takotsubo cardiomyopathy, and the various effects on the heart depending on the duration of IMO stress. We observed the highest incidence of TTC occurred after 5 days of stress. Furthermore, there is a gradual occurrence of electrical and structural remodeling as the stress duration prolongs.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics.

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Acute Coronary Syndrome in Women at the CHU le Luxembourg of Bamako

Introduction: Acute coronary syndromes have been very little studied in the female population in black Africa. Our series showed an increase in the prevalence of acute coronary syndromes in the female population compared to previous studies. Through this retrospective study, we evaluated the epidemiological, clinical, paraclinical, therapeutic and evolutionary specifications of acute coronary syndromes in women. Methodology: This was a retro and prospective study, concerning patients admitted for an acute coronary syndrome over a period of 3 years from September 1, 2019, to August 30, 2022, in the interventional cardiology unit at the CHU le Luxembourg of Bamako. Results: During the study period, 74 patients’ files were collected out of 251 patients, i.e., a frequency of ACS in women of 29.5%. The average age of the patients was 59.31 ± 10.89 years (37 and 83 years) and the age group 45-65 years was the most affected. The risk factors were essentially high blood pressure 66.2% (n=49), physical inactivity 66.2% (n=49) and diabetes 59.5% (n=44). The predominant functional signs were atypical chest pain in 56.8% of cases (n=42). The electrical aspect was mainly persistent ST-segment elevation in 61% (n=45). Seventy-six percent (n=56) of patients were treated 12 hours after the first medical contact. The approach for coronary angiography was radical in 93%. Coronary angiography was pathological in 92% (n=68). Lesions were single vessel in 29.7% of cases and multi-vessel in 62.2% of cases. Conclusion: Acute coronary syndrome in women is characterized by atypical of symptoms with a delay in diagnosis and management. Coronary lesions are characterized by multi-vessel involvement in the majority of cases.

Acute Coronary Syndromes in Women and Men

Acute Coronary Syndromes in Women and Men

Assessment of extra-coronary peripheral arteriopathy in spontaneous coronary dissection: state of the art in non-invasive imaging techniques and future perspectives

Abstract Spontaneous coronary artery dissection (SCAD) has been recognized as an important cause of acute coronary syndrome in women ≤ 50 years old, and up to 43% of pregnancy-associated myocardial infarction. SCAD has a strong association with extra-coronary arteriopathies, including either more common entities such as dissections, intracranial or other aneurysms, and extra-coronary and coronary arterial tortuosity or less common inherited vascular disorders such as Ehlers–Danlos syndrome, Marfan syndrome, and Loeys–Dietz syndrome, leading to the conclusion that systemic arterial disorders may underlie SCAD. Fibromuscular dysplasia is the most common extra-coronary vascular abnormality identified among these patients, also sharing a common genetic variant with SCAD. The American Heart Association, in a scientific statement regarding the management of SCAD, recommends that patients with SCAD should undergo additional evaluation with imaging techniques including either computed tomography angiography (CTA) or magnetic resonance angiography (MRA). MRA has been shown to have sufficient diagnostic accuracy in identifying extra-coronary arterial abnormalities, almost equal to CTA and conventional angiography. The aim of this review is to appraise the most recent important evidence of extra-coronary arteriopathy in the setting of SCAD and to discuss the strengths and weaknesses of various non-invasive imaging methods for screening of extra-coronary arteriopathies in patients with SCAD.

Acute coronary syndrome in women. Are there any special features?

Introduction. The increasing incidence of coronary heart disease, including acute coronary syndrome, among women, the lack of public awareness of the cardiovascular risks in women and the late presentation of these patients for medical care necessitates a review of the existing literature on the problem.Purpose of the work was to systematize data on acute coronary syndrome in women and to characterize its distinctive features.Materials and methods. A literature search was conducted for the period from 2011 to 2022 in PubMed, Cochrane Library, Embase, Google Scholar using the search terms: cardiovascular diseases in women, ischemic heart disease in women, acute coronary syndrome in women and acute myocardial infarction in women. Inclusion criteria: evidence of sex differences in acute coronary syndrome. The preferred languages were Russian and English.Results and discussion. The risk factors of acute coronary syndrome in women are characterized and the data on the peculiarities of the clinic of this pathology are summarized. Data on the problem of a differentiated approach and on the determination of management tactics for patients with acute coronary syndrome are presented.Conclusion. Despite the increasing awareness of cardiovascular disease as a major cause of disability and mortality in both sexes, the attention of specialists to the problem of a differentiated approach to the management of women with ACS remains insufficient, which determines the need for in-depth research on this problem.

Novel Diagnostic Imaging Approach for Patients With Spontaneous Coronary Artery Dissection: The Utility of 18 F-FDG PET Imaging.

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed etiology of acute coronary syndrome in women. Accurate diagnosis remains challenging but is imperative for treatment and prevention. We show here the utility of 18 F-FDG PET imaging in SCAD diagnosis. We present 1 representative case of 4 women with suspected SCAD on coronary angiography from the EVACS (Evolocumab in Acute Coronary Syndromes) clinical trial. 18 F-FDG PET imaging showed acute inflammation in the distribution of the suspected dissected coronary artery identified on angiography. Localized myocardial inflammation identified on 18 F-FDG PET imaging can aid in diagnosing SCAD suspected on coronary angiography.

Predictors of outcomes of acute coronary syndrome in women admitted in the coronary care unit, cardiovascular unit and medical ICU of a tertiary hospital from January 2015 to December 2020

Abstract Funding Acknowledgements Type of funding sources: None. Background Acute Coronary Syndrome (ACS) is a leading cause of demise in the Asia-Pacific region. Women, especially those more than 65 years old, do not seek treatment immediately because symptoms are usually atypical. A study done in the Philippines showed a 100% prevalence of obstructive coronary artery disease (CAD) among women with ACS who underwent cardiac catheterization. Purpose To investigate the demographic and clinical profiles, risk factors, laboratory and diagnostic exam results, and correlation of these parameters to the major adverse cardiac events (MACE) of women with ACS in the coronary care unit, cardiovascular unit, and medical intensive care unit of a tertiary hospital from January 2015 to December 2020. Methods A descriptive retrospective cross-sectional research wherein data from 112 charts were collected and analyzed after approval from the research ethics committee. Results Among the patients, 95.41% are menopause and 78.57% are hypertensive. Chest pain (44.64%) and shortness/difficulty of breathing (53.57%) are the most frequently occurring symptoms with significant p-values of 0.044 and 0.010, respectively. Most patients with unstable angina (UA) (66.67%) and 72.6% of those with non-ST elevation myocardial infarction (NSTEMI) consulted beyond 6 hours after onset of symptoms. The usual site of infarction/ischemia are the anteroseptal and inferior walls, with significant p-values of 0.006 and 0.015, respectively, most frequently occurring in ST elevation myocardial infarction (STEMI) (27.59%). Ejection fractions of less than 40% were seen in 67% of ACS patients; 59% had wall motion abnormalities, 56.7% had aortic sclerosis, 82.47% had mitral regurgitation, 37% had concentric and 26.8% had eccentric left ventricular hypertrophy. Diastolic dysfunction was seen in 80.77% of STEMI patients with a significant P-value of 0.037. Three-vessel CAD was diagnosed in 47.83% of NSTEMI and 52.63% of STEMI patients, with the left anterior descending artery as the culprit lesion in 47.83% and 57.89%, respectively. One or more MACE were documented in 83.93%; 60% had heart failure and 58.93% had prolonged hospital stay. Conclusion The odds of having MACE increased by 5.97% for every year increase in patient’s age. ACS patients with initially elevated troponin I/high sensitivity troponin I, aortic sclerosis, and those who were given diuretics were 5.4, 4.08, and 34.4 times more likely to have MACE, respectively. NSTEMI patients with wall motion abnormalities, obstructive coronary angiograms, and those given diuretics were 13.7, 18, and 19.4 times most likely to experience MACE, respectively. The results emphasize the need to educate Filipino women and the importance of having regular check-ups, maintaining healthy lifestyle, recognizing symptoms, and seeking early consult. These will lead to prompt diagnosis and management of ACS, and eventually, to a decline in ACS-related morbidity and mortality.

ODP148 GENDER AFFIRMING HORMONE THERAPY AND SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract Introduction Spontaneous coronary artery dissection (SCAD) is an important and underreported cause of acute coronary syndrome in women. SCAD has been linked to arteriopathy, pregnancy, as well as hormone replacement therapy in cisgender patients. There is a scarcity of data on the long-term cardiovascular effects of gender affirming hormonal therapy (GAHT) with estrogen. Observational studies have shown increased thromboembolic disease and cardiovascular events in transwomen on estrogen, with oral synthetic or oral combined equine estrogens showing a higher association versus transdermal formulations, however there had been no reports of SCAD in transgender patients on GAHT. Clinical Case A 37-year old transwoman with a history of gender affirming orchiectomy on GAHT with sublingual estradiol 2 mg BID presented with typical symptoms of acute coronary syndrome. No prior history of chest pain. No personal history or family history of cardiovascular disease or risk factors. Initial Troponin I was 9.52 ng/dl (<0. 04 ng/dl), ECG with non-specific ST-changes. A transthoracic echocardiogram showed hypokinesis of the mid anterior and lateral wall. She underwent urgent cardiac catheterization, found to have SCAD of her ramus intermedius. Given the size of the lesion and wall motion abnormalities, a cutting balloon was used to inflate the lesion, and she remained chest pain free during the hospitalization. She was started on Aspirin, Clopidogrel, and Metoprolol. Sublingual estradiol was determined to be her only predisposing risk factor and therefore it was held during her hospitalization and during the lesion healing period, with plans to change to a constant transdermal estrogen patch in the primary care setting. Discussion This is the first case report showing an association of estrogen GAHT and SCAD in a transwoman. SCAD has been observed to occur more often in cisgender women during the late luteal phase and post-partum period, raising the hypothesis that estrogen level fluctuations could potentially play a role. Sublingual estradiol has been shown to have higher peak and trough serum concentration compared to oral estradiol. Research is needed in this area and on the potential adverse cardiovascular effects of GAHT and whether route of estrogen administration plays a role. We support transdermal estradiol in transwomen with or at risk of cardiovascular disease, and close monitoring of serum levels, as well as aggressive treatment of cardiovascular risk factors. Presentation: No date and time listed

Acute coronary syndrome in women: a new and specific approach is needed.

Acute coronary syndrome in women: a new and specific approach is needed.

CHEST PAIN IN WOMEN. IS IT ALWAYS ATHEROSCLEROTIC?

Patients both male and female with diagnosis of Acute Coronary Syndrome (ACS) present with chest pain as presenting complaint. Lichtman JH et al. in his study with ACS showed that 93% of women presented with chest pain or discomfort.1 As compared to men women experience more associated symptoms as primary complaint. The associated symptoms are fatigue, dyspnea, backache, flue like symptoms, indigestion, palpitations and most common is anxiety & feeling scarry.2 Keeping these scenarios in mind one should inquire this associated presentation along with chest pain or discomfort in evaluating ACS in women. In continuation with symptoms there is quite a debate on pathophysiology of Acute Myocardial infraction in men and women regarding coronary pathologic features.3 Type 1 plaque rupture most common in both genders with plaque erosion most common in women in non-obstructive coronary artery disease.4 Spontaneous coronary artery dissection (SCAD) having high mortality exists in the absence of risk factor of ACS.5 It was found in women up to 35% of patients with mean age of 42 to 53 years with a MACE (Major acute coronary event) of 47.4% and 10 years mortality rate of 7.7%2 SCAD seen in peripartum cases, oral contraception use, lack of exercise, connective tissue disorders and vasculidites. It is important for the physician to have in mind these disorders to avoid complications of coronary interventions. In a scientific statement from AHA, Mehte LS et al. showed a lower prevalence of atheroscrotic CAD in women.3 These are certain scoring system,6 that under present women because of vague symptoms and presentation. These scoring systems lead to decrease hospital admission and less noninvasive cardiac testing. For risk satisfaction of chest pain female gender should not be taken as sole criteria for presence or absence of coronary events in presence of other multiple factors. The last but not the least is the psychosocial stress more in women than in men. It has been found that young women who present with early onset myocardial infarction have more psychosocial risk factors in comparison to men of similar age,3 probably having high rates of poverty and trauma exposure during childhood because of various reasons.7 Different studies are endorsing relationship between depression and ischemic heart disease as prognostic factor after ACS.7 In our population where there is lack of education, poverty, awareness of disease especially in women the physician should ponder on different factors mentioned above i.e. presentation perceptions, prevalence, pathophysiology and psychosocial stress for evaluation and management of chest pain.

Sex Differences in Clinical and Angiographic Characteristics in Acute Coronary Syndrome Patients in Dakar, Senegal

Background: Coronary artery disease (CAD) is in relentless progression, along with the adoption of western lifestyle in sub-Saharan Africa. In Senegal, the incidence of acute coronary syndrome (ACS) rose from 5% to 12% in Dakar during the last 20 years. That increase was observed in both women and men, and according to current data, the former paid the heaviest price in terms of mortality compared to men. In this study, we aim to retrospectively assess the clinical characteristics and angiographic profile of ACS in women compared to men in two tertiary care centers in Dakar. Methods: In this study, we retrospectively analyzed and compared data between men and women among 133 patients who underwent coronary angiogram for ACS in 2 tertiary centers from February 2019 to January 2020. Results: A total of 133 patients were included in our study of whom 97 (72.9%) were men. The mean age was 58 ± 13.6 years. Women were older than men (61.4 ± 14.3 years vs 56.6 ± 13.5 years (p = 0.07). Hypertension, sedentary lifestyle and obesity were significantly more frequent in women (69.4%, 52.7% and 19.4%) when compared to men (38.8%, 25.7% and 6.19%) respectively, (p = 0.001; 0.002 and 0.03). Smoking was less frequent in women (2.8%) than in men (44.3%), (p Conclusion: In our study, women with ACS were older, had more cardiovascular risk factors but less angiographic extent of disease than men.

Abstract 12529: Sex-Specific Mortality Associated With High Left Ventricular Ejection Fraction After ST-segment Elevation Myocardial Infarction

Introduction: Using sex-specific cutoffs, high left ventricular ejection fraction (LVEF) is associated with increased mortality in women but not in men with chronic coronary syndromes. Purpose: To explore the association between LVEF and mortality after an acute coronary syndrome in women and men. Methods: Using population-derived sex-specific LVEF cutoffs, we compared characteristics and outcomes of 1,953 ST-segment Elevation Myocardial Infarction (STEMI) patients (1,399 men and 554 women) presenting at Minneapolis Heart Institute between 2003 and 2020. Patients who had a follow-up LVEF measurement available within 2 months of the index hospitalization were included in the analysis. Sex specific cutoffs for post STEMI LVEF were a) for men, >70% (high), 47-70% (normal), <47% (low); b) for women, >72% (high), 50-72% (normal), <50% (low). Standard cutoffs were: >65% (high), 55-65% (normal), <55% (low). Results: When comparing high vs normal vs low LVEF, 1-year mortality was 0% vs 0.8% vs 4.4% in men ( P log-rank <0.001) and 13.3% vs 2.2% vs 3.4% in women ( P log-rank =0.03) (Figure). Five-year mortality was 0% vs 5.1% vs 12% in men ( P log-rank <.001) and 13.3% vs 11.4% vs 19.9% in women ( P log-rank =0.18). The findings were not replicated when standard LVEF cutoffs were used (1-year mortality in women was 6.1% vs 2.5% vs 2.5%, P log-rank =0.33). After adjustment for baseline variables and comorbidities (age, diabetes, dyslipidemia, hypertension, history of MI, door-to-balloon time less than 90 minutes, and the presence of congestive heart failure), high LVEF was associated with 1-year mortality when compared with normal LVEF in women (HR, 10.83; 95% CI, 1.94-60.57, P =0.007). Landmark analysis showed that among women alive beyond 1 year, 5-year mortality was 0% vs 9.4% vs 16.1%, P log-rank =0.31. Conclusion: High LVEF after STEMI using sex-specific cutoffs is associated with lower 1-year survival in women but not in men.

Acute Coronary Syndromes in Women

The Indian Journal of Cardiovascular Disease in Women (IJCDW) is an open access peer-reviewed journal committed to publishing high-quality articles in the field of Cardiovascular Investigations in female patients of different age groups.

When COVID-19 delays the management of an urgent heart condition: A rare case of a spontaneous dissection of two coronary arteries.

Some severe life‐threatening conditions could be misdiagnosed during the current COVID‐19 pandemic.

Hospital healthcare flows: A longitudinal clustering approach of acute coronary syndrome in women over 45 years.

Acute coronary syndrome (ACS) in women is a growing public health issue and a death leading cause. We explored whether the hospital healthcare trajectory was characterizable using a longitudinal clustering approach in women with ACS. From the 2009-2014 French nationwide hospital database, we extracted spatio-temporal patterns in ACS patient trajectories, by replacing the spatiality by their hospitalization cause. We used these patterns to characterize hospital healthcare flows in a visualization tool. We clustered these trajectories with kmlShape to identify time gap and tariff profiles. ACS hospital healthcare flows have three key categories: Angina pectoris, Myocardial Infarction or Ischemia. Elderly flows were more complex. Time gap profiles showed that readmissions were closer together as time goes by. Tariff profiles were different according to age and initial event. Our approach might be applied to monitoring other chronic diseases. Further work is needed to integrate these results into a medical decision-making tool.

Stage 1 hypertension, sex, and acute coronary syndromes during midlife: the Hordaland Health Study.

Hypertension has been suggested as a stronger risk factor for acute coronary syndromes (ACS) in women than men. Whether this also applies to stage 1 hypertension [blood pressure (BP) 130-139/80-89 mmHg] is not known. We tested associations of stage 1 hypertension with ACS in 12329 participants in the Hordaland Health Study (mean baseline age 41 years, 52% women). Participants were grouped by baseline BP category: Normotension (BP < 130/80 mmHg), stage 1 and stage 2 hypertension (BP ≥140/90 mmHg). ACS was defined as hospitalization or death due to myocardial infarction or unstable angina pectoris during 16 years of follow-up. At baseline, a lower proportion of women than men had stage 1 and 2 hypertension, respectively (25 vs. 35% and 14 vs. 31%, P < 0.001). During follow-up, 1.4% of women and 5.7% of men experienced incident ACS (P < 0.001). Adjusted for diabetes, smoking, body mass index, cholesterol, and physical activity, stage 1 hypertension was associated with higher risk of ACS in women [hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.32-3.60], while the association was non-significant in men (HR 1.30, 95% CI 0.98-1.71). After additional adjustment for systolic and diastolic BP, respectively, stage 1 diastolic hypertension was associated with ACS in women (HR 2.79 [95% CI 1.62-4.82]), but not in men (HR 1.24 [95% CI 0.95-1.62]), while stage 1 systolic hypertension was not associated with ACS in either sex. Among subjects in their early 40s, stage 1 hypertension was a stronger risk factor for ACS during midlife in women than in men.

HIGH-NORMAL BLOOD PRESSURE IS PARTICULARLY ASSOCIATED WITH INCREASED RISK FOR ACUTE CORONARY SYNDROMES IN WOMEN: THE HORDALAND HEALTH STUDY

Abstract Objective: Hypertension is a major risk factor for acute coronary syndromes (ACS). Less is known about whether high-normal blood pressure (BP) carries a different risk for ACS in women and men. We tested associations of high-normal BP with incident ACS in women and men participating in the community-based Hordaland Health Study (HUSK). Design and method: We followed 8262 participants aged 42 years (52% women) in HUSK from 1992/93 through 2009 by coupling them to the Cardiovascular Disease in Norway (CVDNOR) project and Cause of Death Registry. BP was measured at baseline in triples at after at least 2 minutes rest in seated position with calibrated sphygmomanometers in 1992/93. The average of the two last measurements was taken as the clinic BP measure. The cohort was divided according to BP class: normal BP (BP &lt; 130/85 mmHg), high-normal BP (BP130–139/85–89) and hypertension (BP &gt; 140/90 or use of antihypertensive drugs). ACS was defined as hospitalization or death with an acute myocardial infarction or unstable angina pectoris diagnosis (ICD-9 codes 410, 411 and ICD-10 codes I20.0, I21 and I22) in the period 1994–2009. The association between BP category and ACS was tested in sex-specific Cox regression analyses adjusted for diabetes, smoking and total cholesterol. Normal BP was used as the reference group. Results: At baseline, 17% women and 27% men had high-normal BP and 16% women and 32% men had hypertension (both p &lt; 0.001 between sexes). During follow-up, 1.4% of women and 6.1% of men experienced an ACS (p &lt; 0.001). In multivariable analyses in women, both hypertension and high-normal BP were associated with incident ACS (hazard ratio (HR) 2.79, 95% confidence interval (CI) 1.36–5.72 and HR 2.22, 95 % CI 1.05–4.71, respectively). In men, hypertension but not high-normal BP was associated with incident ACS (HR 1.63, 95 % CI 1.16–2.30 and HR 1.20, 95 % CI 0.81–1.77 respectively). Conclusions: In the Hordaland Health Study, high-normal BP was a stronger risk factor for ACS in middle-aged women than men. Our findings suggest that sex-specific diagnosis of high-normal BP and hypertension may be warranted.