Sex and gender in depression after percutaneous coronary intervention: clinical patterns, mechanistic hypotheses, and care pathways

Depressive symptoms are common after percutaneous coronary intervention (PCI) and are associated with poorer recovery, lower adherence to secondary prevention, reduced participation in cardiac rehabilitation, and a higher risk of adverse cardiovascular outcomes. Evidence also suggests that depression after PCI is not experienced, detected, or managed in the same way across sex and gender groups. Women are more often reported to have higher early symptom scores, greater anxiety comorbidity, more somatic symptom overlap, and lower access to some forms of guideline-based cardiovascular care. Men may be less likely to disclose affective symptoms and may present psychological distress through externalizing behaviors, treatment disengagement, smoking, alcohol use, anger, or delayed help-seeking. These patterns should not be interpreted as fixed male-female traits. Rather, they probably reflect interactions among biological sex-related factors, social gender norms, comorbidity, age, socioeconomic position, and healthcare access. Unlike previous reviews that pool depression across coronary syndromes, this review is organized around patients after PCI, explicitly distinguishes conclusions directly supported by post-PCI data from those extrapolated from broader coronary populations, and identifies the remaining extrapolations as research priorities. This narrative review summarizes clinical patterns of depression after PCI, discusses plausible biological and psychosocial mechanisms, and proposes a sex- and gender-informed care pathway for screening, referral, cardiac rehabilitation, and follow-up. The available literature supports a more cautious and individualized approach than a simple binary model: screening tools should be interpreted alongside clinical interview and behavioral indicators; rehabilitation should address practical barriers, stigma, caregiving burden, and functional goals; and future studies should report sex-disaggregated data while also measuring gender-related exposures.