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Coronary artery disease remains the most common cause of morbidity and mortality in the general population. Several studies in developed countries have reported a gender-related difference in ST-segment elevation myocardial infarction (STEMI) in terms of risk factors, clinical presentation, delays in management, therapeutic modalities, and in-hospital as well as one-year outcomes. Data from non-developed countries about women with STEMI remain rare. We therefore aimed through this study to investigate the baseline characteristics of STEMI in Tunisian women compared to men and to determine the impact of gender difference on STEMI complications, in-hospital mortality, and one-year follow-up outcomes.All patients presenting to our center for STEMI between January 2001 and January 2021 were retrospectively enrolled in this analysis. Clinical features, therapeutic management, and in-hospital as well as one-year outcomes were compared between women and men. Predictive factors of in-hospital mortality in women were determined.Out of 1670 STEMI hospitalizations, 359 (21.4%) were female. Compared to male, female had higher rates of hypertension (51.5% vs. 24.4%, p0.001), diabetes (50.1% vs. 32.2%, p0.001), and obesity (63.8% vs. 55%, p = 0.003). The clinical presentation was characterized by less prevalent inaugural chest pain (58.8% vs. 68.6%, p0.001). Atypical symptoms were significantly higher in women compared to men (55.2% vs. 5%, p0.001). On admission, women had higher prevalence of anemia, renal failure, and hyperglycemia compared to men. Primary percutaneous coronary intervention (pPCI) was the reperfusion strategy of choice in 37.9% of women vs. 33.1% of men (p=0.02). Women were significantly less likely to receive thrombolysis (p = 0.004), with a significantly less prevalent successful thrombolysis (55.6% vs. 67.2%, p=0.013). In-hospital mortality was markedly higher in women compared to men (12.8% vs. 7.3%, p=0.001). Compared to surviving women (n = 313), those who died (n = 46) frequently had more diabetes and hypertension (65.2% vs. 47.9%, p= 0.02 and 67.4% vs. 49.2%, p = 0.02, respectively). New-onset atrial fibrillation, acute left heart failure, cardiogenic shock, ventricular tachycardia, and atrioventricular block markedly occurred in women who died (52.2% vs. 23.3%, p=0.001; 17.4% vs. 1.9%, p0.001; 19.6% vs. 8.3%, p = 0.016; 15.2% vs. 1.6%, p0.001 and 34.8% vs. 10.2%, p0.001, respectively).Compared to men, Tunisian women presenting for STEMI had higher prevalence of risk factors and atypical symptoms. Women had more in-hospital complications and mortality.