Abstract: Introduction and objectives: Ischemic heart disease remains a leading cause of mortality, with women facing unique social and clinical challenges that impact outcomes. This study aimed to examine sex and gender specific differences in social and clinical predictors of long-term outcomes in coronary artery disease. Materials and methods: This prospective cohort study used the RECORVAL registry, including patients with coronary artery disease undergoing coronary angiography. Clinical data were extracted from electronic health records, and social determinants were collected via a structured questionnaire. Outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction, revascularization, stroke, major bleeding and a composite endpoint (cardiovascular death, myocardial infarction or revascularization). Sex-stratified Kaplan-Meier curves, Fine-Gray competing risk models, and multivariate Cox regression models adjusted for social and clinical variables were used. Results: Among 2219 patients (23.4% women) followed for a median of 2421 days, women were older (68.5 vs. 64.3 years) and had greater social disadvantages, including lower education, employment, and internet access. Percutaneous intervention rates were similar, but coronary artery bypass grafting was less frequent in women (3.5% vs. 6.0%). No significant differences were observed in all-cause or cardiovascular mortality (aHR 0.80; 95% CI 0.51-1.24). Women showed a non-significant trend toward lower composite endpoint risk (aHR 0.81; 95% CI 0.64-1.04), lower myocardial infarction and revascularization risk, and higher major bleeding (aHR 1.39; 95% CI 0.92-2.11). Conclusions: Women face significant social disadvantages requiring personalized prevention addressing gender-specific risks. Similar mortality rates suggest improving equity, while differing ischemic?haemorrhagic profiles call for sex-tailored therapy to improve outcomes.

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