Italian Registry Finds Women's Heart Attacks Often Go Unrecognized Until Too Late

When a middle-aged man arrives at an emergency department with chest pain, the clinical path is well-worn. When a 68-year-old woman arrives with the same symptom - one whose most recent medical concern was a miscarriage or an autoimmune diagnosis years earlier - the cardiovascular risk profile that led her there may have gone unrecognized for her entire life. That gap is exactly what a new Italian registry is designed to close.

The GEDI-ACS registry - Gender, Diversity and Inclusion - Acute Coronary Syndromes - is the first multicentre, prospective Italian registry dedicated exclusively to studying acute coronary syndromes (ACS) in women. Preliminary findings from the first 68 enrolled patients, presented at the EAPCI Summit 2026 in Munich, offer an early portrait of who these women are, what conditions preceded their cardiac event, and what distinct challenges they face in recovery.

A first event, not a known disease

The most striking finding may be the most fundamental: for 86% of the women enrolled, the acute coronary event was their first-ever manifestation of cardiovascular disease. They had not been previously diagnosed with coronary artery disease or managed as cardiac patients. Their first encounter with the cardiovascular system came in the form of a heart attack or unstable angina.

Chest pain was the primary presenting symptom in 88.2% of cases. The breakdown of ACS type was 38.2% ST-segment elevation myocardial infarction (STEMI), 36.8% non-ST-segment elevation MI (NSTEMI), and 25.0% unstable angina. No deaths, strokes, or reinfarctions occurred in the first 30 days, though 11.3% experienced recurrent chest pain.

"ACS often represented the first cardiovascular event," said Dr. Francesca Napoli from IRCCS San Raffaele Scientific Institute in Milan, the study's lead investigator. "The common coexistence of ACS with noncardiac comorbidities, miscarriage and premature menopause provide insights into how we may be able to tailor preventive approaches."

MINOCA: heart attacks without blocked arteries

Over one-third of the women - 38.2% - had myocardial infarction with non-obstructive coronary arteries, a condition known as MINOCA. In MINOCA, standard coronary angiography does not reveal the major blockages typically seen in heart attacks, but the heart has still sustained injury. The condition is more common in women than men and is poorly understood. Optimal treatment remains undefined, and clinical guidelines offer limited guidance.

"MINOCA was also a frequent finding and yet the best way to treat it is still unknown," Dr. Napoli noted. Its high prevalence in this cohort - more than one in three cases - underscores why a women-focused registry matters. Standard cardiovascular research, in which women are historically underrepresented, has produced less data on MINOCA than on obstructive coronary disease.

A risk profile shaped by more than cholesterol

The women enrolled in GEDI-ACS carried a heavy burden of traditional cardiovascular risk factors: 83.6% had dyslipidaemia, 77.9% had hypertension, and 50.0% had a history of smoking. But the registry also captured risk factors and comorbidities specific to or more prevalent in women. Among the 68 patients, 32.3% reported a history of miscarriage and 16.2% reported premature menopause. Autoimmune diseases were present in 32.2% of patients, and 16.2% had a prior cancer history.

Nearly half - 42.6% - reported anxiety or depression. And 85.3% had low health literacy, a measure of the ability to access, understand, and use health information to make decisions.

"The high levels of anxiety/depression and poor health literacy we found are important considerations as we try to support women with ACS more effectively to enhance recovery," Dr. Napoli said. Low health literacy in particular can limit a patient's ability to adhere to post-discharge medications, follow dietary guidance, or recognize symptoms of recurrence.

Registry design and current scale

GEDI-ACS is enrolling 100 consecutive women across four centres: IRCCS San Raffaele Scientific Institute and Centro Cardiologico Monzino in Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico in Milan, and AOU Federico II Naples. The sites were chosen to capture geographic, socioeconomic, and cultural diversity across Northern and Southern Italy. The median patient age in the current cohort is 68 years, and 7.4% of enrolled women are non-Caucasian.

The registry collects clinical, sex-specific, socioeconomic, psychosocial, biochemical, and molecular data - a scope considerably broader than standard cardiovascular registries. Principal Investigator Professor Alaide Chieffo, EAPCI President, said the team plans to combine clinical findings with genetic and molecular data as enrollment continues.

A small but important caveat

The current dataset covers only 68 patients - far below the eventual enrollment target and too small for definitive conclusions. These are preliminary descriptive findings without a male comparator group or a randomized design. The registry cannot yet establish causal relationships between the risk factors observed and cardiovascular outcomes. Long-term follow-up data, which would show whether the risk profile at presentation predicts recurrence or mortality, are still being collected.

The registry was funded by the European Union's Next Generation EU program, under Italy's National Recovery and Resilience Plan.