STEMI comprises 25–40 % of ACS presentations in observational studies. According to the most recent National Registry of Myocardial Infarction 4 (NRMI-4), that number is around 29 % of ACS presentations [25, 26]. Significant improvements in the understanding the pathophysiology of atherosclerosis, especially the mechanism of acute myocardial infarction and intervening with appropriate therapies has resulted in not only a decreased incidence of recurrent STEMI, but also improved mortality rates, both in-hospital (5–6 %) and at 1-year (7–18 %) [27, 28].

Approximately 20–30 % of patients presenting with STEMI are women [29, 30]. In earlier STEMI trials women were significantly underrepresented. This is thought to be due to the basic pathophysiologic difference in ACS presentation between men and women. Women presented more often with NSTEMI as they tended to have more atherosclerotic plaque erosion whereas men had plaque rupture and vessel occlusion [8, 31]. However the proportion of women, especially younger women, has increased in the STEMI population. This proportionate increase in women seems to be related to an increase in risk factors such as smoking and obesity in these studies suggesting possible change in plaque pathophysiology and, therefore, plaque instability. Also, women tend to have increased mortality after a STEMI compared to men despite receiving optimal or similar therapy to men [29, 32]. Women also seem to have higher incidence of complications from the therapy administered including more bleeding from antiplatelet and lytic therapy, more vascular complications, and also increased rates of renal failure [32–35]. Thus the increase in the incidence of STEMI in women combined with the higher mortality despite optimal therapy, and higher complication rates with invasive and non-invasive therapy make them a unique group requiring special consideration and more dedicated research.

The treatment of STEMI includes the acute phase and long term management phase. The acute management includes pre-hospital management, reperfusion strategies, and the management of the hospitalization including the complications of the MI and the reperfusion strategy selected.

Initial studies raised the concern, which was probably justified during that time period that women were not getting standard of care management for their STEMI presentations. In the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) registry female gender was a strong independent predictor of a failure to receive reperfusion therapy among patients who had no contraindications [36]. Women included in the NCDR (National Cardiovascular Data Registry) ACTION Registry–GWTG (Get With The Guidelines) presented later after symptom onset, had longer door-to-fibrinolysis or door-to-balloon (or device) (D2B) times, and did not receive aspirin or beta blockers within 24 h of presentation as often [36]. However, a recent assessment of the effects of a statewide program for treatment of STEMI suggests significant improvements in treatment times that were similar for whites and blacks and for women and men [37]. Recognizing the problem has been the real challenge in pre-hospital management of STEMI in women. Women tend to present with atypical symptoms delaying the initial diagnosis [38]. However, once the diagnosis has been established the morbidity and mortality are driven by the patient’s co-morbidities rather than by sub-optimal treatment. There are still regional differences in symptom recognition to ECG time and also symptom onset to hospital time as demonstrated by multiple studies [39, 40]. Thus, there is a need for more campaigns to educate women and health care workers to recognize atypical symptoms for angina, and obtain a timely ECG as soon as it is recognized.

Once EMS suspects a possible ACS on a call the patient is asked to chew 324 mg (four 81 mg tablets) of aspirin to help hasten the onset of systemic action. Nitroglycerin in the appropriate clinical setting may help with some symptom relief, but has not demonstrated any mortality benefit in trials. Also, caution should be exercised with inferior STEMI patients as right ventricular involvement of the infarction could potentially cause significant hypotension with nitroglycerin. Oxygen therapy is routinely administered and has no proven harm and opioids seem to relieve anxiety and pain. Activation of the STEMI alarm at hospitals that perform primary PCI by the EMS personnel from the field has resulted in shorter door to balloon times resulting in better outcomes [41].

Once in the emergency room, the focus shifts to choosing the appropriate reperfusion strategy [42]. If primary PCI is available, it should be performed in the shortest time possible. The ACC/AHA guidelines recommend that reperfusion (the door to balloon time) be achieved in <60 min from time of arrival to the ED. If primary PCI is not available and the nearest primary PCI center is >120 min away, then the ACC/AHA Class 1 recommendation is to consider thrombolytic therapy if no contraindications exist. If thrombolytic therapy is the reperfusion strategy of choice for the patient, it should be accomplished within 30 min of arrival to the ED. Dual anti-platelet therapy should be initiated as soon as possible. Currently, there are three drug options are available for patient’s undergoing urgent PCI: clopidogrel, prasugrel, and ticagrelor. No published literature exists on gender specific differences in the type of thrombolytic therapy or anti-platelet agents.

PCI: Invasive reperfusion therapy has no significant gender related issues per se. In general, women tend to have more diffuse disease in significantly smaller vessels making them less than ideal for PCI. Women tend to be older than men at the time of presentation, with more comorbidities and, therefore, they tend to have more complex lesions. For these reasons the procedural success rate in women in various studies is lower than that of men [42]. Also, patients with failed PCI attempts have a higher short term and long term mortality, in some studies up to 20 and 50 %, respectively [43]. The evidence suggests that MACE is reduced with placement of a stent when compared to balloon angioplasty alone in STEMI. Even though they have smaller caliber vessels and a higher incidence of DM requiring smaller stents, both risk factors for in-stent restenosis, women tend to have a lower incidence of restenosis compared to men [44]. The drug eluting stents seem to perform equally well in women and men [45]. Thus, it appears that choice of stent should not be guided by gender differences.

Data from several sources suggest that gender-related differences exist in bleeding complications in ACS patients. In a multivariate analysis by Subherval et al., female gender was identified as an independent predictor of major in-hospital bleeding (OR 1.31, 95 % CI 1.23–1.39) in patients with ACS [83]. In the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines) registry, women who underwent PCI for UA/NSTEMI, had a much higher risk of major in-hospital bleeding compared to men (14.1 % vs 5.9 %, p < 0.001) [84].

Women undergoing PCI tend to have more access- related bleeding. In contrast, men tend to have GI bleeding after an MI. Possible explanations for this finding include smaller blood vessels in women and specific vascular reactivity [55]. In the same registry, a significant interaction was found between gender, GP IIb/IIIa inhibitor use and bleeding risk (p = 0.014). The increased risk of bleeding due to use of GPIIb/IIIa or anticoagulant agents like UFH or enoxaparin, may be related to excessive dosing of those agents (15 % of major bleeding events observed were due to excess drug doses) [64, 83, 84]. After adjusting for age, weight, and renal function, women remained at higher risk for excessive dosing and major bleeding events, as the authors found that excessive dosing of antithrombotic agents occurred in 72 % of women compared to 27 % of men [85, 86]. However, the ISAR- REACT and ACUITY trials [85, 86] provide data to suggest that bleeding complications remain higher among women compared to men even when they receive appropriate doses of antithrombotic agents.