<b>Sex Disparities in Ischemic Heart Disease: An Algerian Multicenter Cohort</b>

Background: Despite advances in cardiovascular care, significant sex-based disparities persist in ischemic heart disease (IHD) management and outcomes. Women remain underdiagnosed and undertreated, with distinct pathophysiological mechanisms that conventional approaches often fail to address. Methods: In this multicenter, retrospective cohort study, we analyzed 748 patients with IHD (389 men, 359 women) from four tertiary cardiology centers (2017–2025). Using propensity-score matching (SuperLearner algorithm), we balanced cohorts by age, cardiovascular risk (SCORE2), and center protocols. Natural language processing (BioBERT) extracted unstructured data from 12,346 clinician notes. Primary outcomes included major adverse cardiovascular events (MACE); secondary outcomes comprised heart failure hospitalizations, angina burden (CCS class), and functional status (NYHA). Machine learning (XGBoost) identified sex-specific mortality predictors. Results: Women exhibited higher hypertension burden (81.2% vs. 74.3%, *p*<0.001) and resistant hypertension rates (37% vs. 22%), yet poorer glycemic control (mean HbA1c 7.4% vs. 6.3%, *p*=0.003). Revascularization rates were significantly lower in women (49% vs. 72%, *p*<0.001) despite similar SYNTAX scores. Women also received shorter dual antiplatelet therapy duration (8.7 vs. 12.1 months, *p*=0.008) and fewer direct oral anticoagulants (43% vs. 68%, *p*<0.001). Outcomes diverged: sudden cardiac death predominated in men (78%, *p*=0.01), while heart failure-related deaths were higher in women (63%, *p*=0.02). Microvascular dysfunction was more prevalent in women (53% vs. 22%, *p*<0.001). COVID-19 exacerbated disparities, with women delaying acute coronary syndrome presentation by 38% versus men (*p*=0.01). Conclusions: This study reveals systemic sex disparities in IHD care, from risk factor control to treatment allocation and outcomes. Women face under-recognition of microvascular dysfunction and therapeutic inertia, contributing to excess heart failure mortality. These findings underscore the urgent need for sex-specific management algorithms to improve cardiovascular outcomes.