Acute coronary syndromes (ACS) represent a continuum from unstable angina to non-ST-elevation myocardial infarction. ACS is the preferred diagnostic term for non transmural myocardial infarction. The different forms of ACS share a common anatomic substrate consisting of atherosclerotic plaque rupture or erosion, with variable degrees of thrombus formation and compromised blood flow to viable myocardium. Patients with ACS have a heterogeneous profile of short- and mid-term adverse outcomes and require a tailored approach. Recent major advances in the management of ACS have emphasized the importance of earlier identification of higher-risk patients, whose outcome might be improved by aggressive revascularization. However, during the past several years, numerous studies have shown a significant difference in the prognosis of women and men with ACS. Some reports have concluded that women have a worse prognosis than men after thrombolytic therapy and/or coronary angioplasty with stenting for myocardial reperfusion. The aim of our retrospective study was to determine sex differences in outcomes after early percutaneous intervention (PCI) in high-risk patients with acute coronary syndromes (ACS). A total of 694 consecutive patients (151 women with 233 treated lesions and 543 men with 850 treated lesions) were included. Enrollments were limited to ACS patients judged to be at high risk [unstable angina/non ST-elevation myocardial infarction with recurrent ischemia/dynamic ST segment changes (53.6% vs 52.4%) or post-infarction unstable angina (46.4% vs 47.6%)] who underwent PCI within 24 hours of admission if the coronary anatomy was deemed suitable. The two groups were well matched for clinical and lesion characteristics, except that the women, as in other studies, were older (67.9 +/- 11.3 vs 62.3 +/- 12.3 years) and had a higher prevalence of hypertension. All the lesions were treated by stent implantation, and glycoprotein IIb/IIIa inhibitors were used similarly in the two sexes (27.1% of women, 30.5% of men). The success rates were similar (94% and 93.7%), with a similar incidence of in-hospital MACE (4% vs 3.8%, p = 0.56). After a mean follow-up of 564 +/- 294 days, the two groups had similar rates of mortality (2% vs 3.2%), myocardial infarction (6.7% vs 7.1%) and repeated revascularization (7.2% vs 8.3%). The respective event-free survival rates were 88 +/- 60.3% and 83 +/- 0.3% at 1 year and 87% vs 78 +/- 0.2% at 2 years (p = 0.58). Previous studies have shown increased morbidity and mortality associated with recurrent ischemia and myocardial infarction in women after acute revascularization for ACS. Our study confirms that aggressive revascularization offers a comparable survival benefit in the two sexes. Women with ACS who are at high risk derive the same benefit as men from early angioplasty and coronary stenting of the culprit lesion, with satisfactory in-hospital and mid-term outcomes.