A review of the common causes of acute coronary syndrome (ACS) in females, and the role of estrogen on its pathologies and risk factors.

As our understanding of acute coronary syndromes (ACS) has increased, we have been able to better delineate the unique pathologies that cause ACS. This review article on the common causes of ACS in females explores the atherosclerotic pathologies of plaque rupture and plaque erosion, and non-atherosclerotic pathologies of SCAD, MINOCA and Takotsubo cardiomyopathy. It reviews the literature on the link between estrogen and its protection against both atherosclerotic risk factors and induction of plaque vulnerability. The mechanistic plausibility of estrogen causing higher risk in SCAD, MINOCA and Takotsubo cardiomyopathy, the female-predominant non-atherosclerotic ACS presentations are also summarised. Whilst there is still much to be researched about these pathologies, an analysis of the biological impact of sex hormones at the molecular level has helped identify links between mechanisms suggesting a possible unifying pathology between plaque erosion, MINOCA and microvascular spasm. In this way, a new paradigm for ACS as an equilibrium between thrombus-stabilisation and thrombus-dissolution states is also explored in this article. What has become evident is that the attempt to understand the common causes of ACS in females has resulted also in a deeper understanding of atherosclerotic ACS in males, and highlighted areas of exciting further discovery.