AHA Statement Calls for Cause-Specific Approach to Acute Coronary Syndromes in Younger Women
USA: The American Heart Association (AHA) has issued a 2026 scientific statement highlighting the distinct causes, diagnostic challenges, and management considerations of acute coronary syndromes (ACS) in premenopausal women. The statement, published in Circulation, emphasizes that ACS in younger women should not be viewed simply as premature atherosclerotic disease, as nonatherosclerotic and nonobstructive mechanisms are more frequently involved.
Premenopausal women have higher rates of conditions such as spontaneous coronary artery dissection (SCAD), myocardial infarction with nonobstructive coronary arteries (MINOCA), and coronary vasospasm compared with older patients. Female-specific factors, including pregnancy-related complications, preeclampsia, hormonal influences, and early menopause, may further modify cardiovascular risk. These differences can make diagnosis challenging and contribute to uncertainty about optimal treatment.
Key Recommendations:
- Consider diverse causes of ACS: Clinicians should evaluate SCAD, MINOCA, coronary vasospasm, plaque disruption, and other nonatherosclerotic mechanisms rather than assuming obstructive coronary disease.
- Use advanced imaging when appropriate: Conventional coronary angiography may not identify SCAD or subtle plaque abnormalities. Intracoronary imaging and multimodality imaging can help establish the underlying cause.
- Tailor treatment to the mechanism: Women with atherosclerotic ACS should receive standard guideline-directed medical therapy, while treatment should be modified for nonatherosclerotic causes.
- Manage SCAD conservatively when possible: Routine PCI should generally be avoided in stable SCAD because intervention can carry additional risks. Prolonged dual antiplatelet therapy (DAPT) is also not routinely recommended unless PCI or plaque disruption provides a specific indication.
- Individualize antiplatelet therapy: DAPT should generally be reserved for patients undergoing PCI or those with evidence of plaque disruption rather than used routinely in SCAD or vasospastic ACS.
- Consider β-blockers in selected MINOCA patients: They may help reduce recurrent events in some women, depending on the underlying mechanism.
- Intensify long-term prevention: Given the substantial lifetime cardiovascular risk following ACS at a young age, aggressive management of modifiable risk factors is recommended. LDL cholesterol targets in the range of <55–70 mg/dL and systolic blood pressure <120 mm Hg, when tolerated, may be considered.
- Assess female-specific risk factors: A history of preeclampsia, pregnancy-related complications, premature or early menopause, and other reproductive factors should be incorporated into cardiovascular risk assessment.
The statement also highlights significant gaps in evidence, particularly regarding SCAD and MINOCA, where many treatment decisions remain based on observational evidence and clinical experience. The AHA therefore calls for greater recognition of these conditions and more research to establish evidence-based management strategies.
Overall, the scientific statement encourages clinicians to take a cause-specific and sex-specific approach to ACS in premenopausal women. Recognizing nonatherosclerotic mechanisms, using appropriate imaging, avoiding unnecessary interventions, and initiating aggressive lifelong risk-factor management may help address the underdiagnosis and undertreatment of cardiovascular disease in this population.
Reference:
Kovacic JC, et al. Acute coronary syndromes in premenopausal women: A scientific statement from the American Heart Association. Circulation 2026 Feb 17; 153:e89. DOI: 10.1161/CIR.0000000000001416.
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