There is conflicting evidence regarding the benefit of an early invasive strategy in women with NSTE-ACS [7]. Indeed, while post hoc analysis of the FRISC II and RITA 3 trials showed no benefit of an invasive strategy in women, in contrast to its beneficial effect in men, the TACTICS-TIMI 18 indicated similar benefits of a routine early invasive versus a conservative (ischemia-guided) strategy in men and women. Caution is needed in interpreting the findings of these subgroup analyses, as differences in clinical and angiographic risk profile between women and men, and the markedly lower number of women included in those trials may explain the observed interaction of sex subgroup with the treatment effect of an invasive strategy in NSTE-ACS. Moreover, several important differences between the latter randomized trials may explain the discordant findings and the lack of benefits from a routine invasive strategy compared with a conservative strategy. For instance, in the FRISC II trial, the excess of risk with the invasive strategy group among women was driven by a particularly high CABG-related mortality; the RITA 3 trial included a cohort of women at lower risk, with no or single-vessel disease in the majority of cases (67 %) and lower rates of death and MI at 1 year in women in both the invasive (8.6 %) and conservative groups (5.1 %) than those of patients enrolled in the FRISC II and TACTICS-TIMI 18 trials. Importantly, in the TACTICS-TIMI 18 trial, the benefit of an early invasive therapy, in terms of significant reduction in death and MI at 1 year, was further enhanced in women with elevated troponin T levels [7]. Differently, women with NSTE-ACS and no elevation in troponin who underwent an early invasive strategy had a nonsignificant increase in events, as did women with a low-risk TIMI score. The meta-analysis by the Cochrane Collaboration pointed out that women derive a significant reduction in death or MI for a routine invasive versus a conservative strategy, although with an early hazard due to an increase in procedure-related events, including periprocedural MI and bleeding, suggesting the adoption of strategies minimizing these events especially in women (i.e., optimization of stenting strategies, staged PCI procedures, accurate selection of upstream and periprocedural medical therapy, and antithrombotic regimens and radial access). It has been shown that when bleeding avoidance strategies are not used, women have significantly higher rates of bleeding than men. Both genders have similar adjusted risk reductions of bleeding when any of those strategies are used. Thus, overall available data suggest that a routine early invasive strategy should be considered in women on the same principles as in men, that is, after careful risk stratification for both ischemic and bleeding risks including clinical and ECG evaluations, analysis of biomarkers, comorbidities, and use of risk scores. Indeed, as stated above in the paragraph on prognosis, sex-based differences in 30-day mortality observed among ACS patients are markedly attenuated after adjustment for baseline characteristics, angiographic disease severity, and treatment strategies in a cohort of 35,128 patients with angiographic data, taken from a pooled analysis of 11 trials [3]. Based on these overall evidences, according to the NSTE-ACS guidelines, both genders should be evaluated and treated in the same way for acute care and for secondary prevention. Women with NSTE-ACS and low-risk features should not undergo early invasive treatment because of the lack of benefit and the possibility of harm. The guidelines point out that particular attention to weight and/or renally calculated doses of antiplatelet and anticoagulant agents has to be placed to reduce bleeding risk among women. Despite the higher number of risk factors, the lack of gender differences in treatment guidelines, and no observed sex-specific treatment effect for most therapeutic agents, women with NSTE-ACS compared with men are less likely to receive evidence-based therapies including both invasive coronary angiography and revascularization [4]. Of interest, even after adjusting for age, cardiovascular risk factors, and extent of disease, myocardial revascularization (PCI or CABG) in patients with significant CAD was less frequently used in women. This has an important prognostic impact as it has been shown that elderly women who are not revascularized have a threefold higher in-hospital and 1-year mortality rate compared with revascularized women with no increased severe bleeding in this latter group undergoing revascularization [9]. Therefore, elderly women with an NSTEACS should not be denied an evidence-based diagnostic and therapeutic approach because of presumptive excess in risks.