Top Things to Know: Acute Coronary Syndromes in Premenopausal Women
Published: February 03, 2026
Prepared by Anne Leonard MPH, RN, FAHA – National Senior Director Science and Medicine
- Premenopausal women presenting with acute coronary syndrome (ACS) are a unique and often under-recognized patient population. These women have traditionally been considered to be at lower cardiovascular risk than other groups. There is a growing appreciation of the potential risk for ACS in this younger subset of women.
- To date there has been no attempt to develop integrated management pathways for the diagnosis and management of premenopausal women presenting with ACS.
- Presentation and diagnosis in the emergency department (ED)
- Women with ACS may report a range of symptoms such as pain/discomfort (back, shoulder, chest, neck and jaw), epigastric and gastrointestinal symptoms (indigestion, nausea, stomach pain, vomiting, pressure, burning, discomfort), non-specific symptoms (sweating, anxiety, fatigue and dizziness), and nuanced/subtle symptoms (feeling ‘something is off’).
- While there may be variability of presentation and symptoms, the most common symptom in young women with ACS is chest pain – described as pain, pressure, tightness or discomfort. Previous American Heart Association surveys of United States women (age ≥ 25 years) conducted in 2009 and 2019 have demonstrated poor awareness of myocardial infarction symptoms among young women.
- Premenopausal women with ACS experience gaps in care due to delays in seeking acute/emergency care and in ED diagnosis and treatment.
- Selection of invasive versus non-invasive (invasive angiography or coronary computed tomography angiography) diagnostic testing for premenopausal women with ACS should be based primarily on risk.
- This statement discusses key considerations for invasive angiography, revascularization, and related procedures such as arterial access, intravascular imaging, left ventricular angiography, invasive physiology, and provocative testing.
- Considerations for revascularization in spontaneous coronary artery dissection (SCAD), coronary artery bypass grafting, angiography and revascularization in pregnant patients, angiography and revascularization in breastfeeding women with ACS, are described in this paper.
- Medical therapies and the management of risk factors in non-pregnant and pregnant patients are reviewed in this statement. Contraception counseling are also important discussions in the management of risks in premenopausal women.
- Cardiac rehabilitation is highlighted as an important part of the post ACS episode.
- As post-ACS depression and anxiety is common in all patients with ACS, important points of management are discussed in this statement for the premenopausal population of women.
- Many of the relevant etiologies of ACS in premenopausal women are seen less commonly than atherosclerotic coronary artery disease in general, and the corresponding lack of robust clinical trial data, means that clinicians are less certain about the optimal diagnostic and management pathways needed for clinical care. Specific pathways for premenopausal women with ACS have not yet been developed, but this statement has sought to address specific issues related to this population of women as a start toward potential pathways for treatment and management in this population.
Citation
Kovacic JC, Reynolds HR, Alasnag M, Blakeman JR, Ijioma NN, Kim ESH, Sandner S, Sanghavi M, Saw J, Tamis-Holland JE; on behalf of the American Heart Association Cardiovascular Interventions Committee of the Council on Clinical Cardiology and the Women’s Health Science Committee of the Council on Clinical Cardiology and Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Council on Quality of Care and Outcomes Research. Acute coronary syndromes in premenopausal women: a scientific statement from the American Heart Association. Circulation Published online February 3, 2026. doi: 10.1161/CIR.0000000000001416