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Introduction: Information on sex differences in clinical presentation and outcomes of STEMI with nonobstructive CAD is poor as prior studies have pooled together all patients with MI. STEMI and NSTEMI are clinical entities that differ considerably in the pathophysiology and management options Hypothesis: The current study aimed to determine the clinical characteristics, outcomes and predictors of STEMI by sex and CAD status Methods: We identified 5858 patients who underwent coronary angiography for STEMI in the ISACS-TC registry from 2010-2016. Patients with prior revascularization (n=797) and cardiomyopathies/myocarditis (n=12) were excluded, giving a final study population of 5049 STEMI patients. The primary outcome measure was all cause 30 day death. Secondary outcome was the incidence of severe left ventricular dysfunction at discharge (EF<30%). Risk factors, clinical history, presentation, and hospital treatments within 24 hours from admission were compared by sex and CAD status (obstructive vs nonobstructive) by multivariable logistic methods Results: Of the 5049 STEMI patients, 94.2% had significant CAD and 5.8% had nonobstructive CAD. Younger age (OR 1.19 CI 1.05- 1.35), prior MI (OR 1.66 CI 1.01-2.76) and prior heart failure (OR 2.09 CI 1.11-3.92) were independent determinants for clinical presentation with STEMI and nonobstructive CAD. There were no differences between men and women in rates of nonobstructive CAD (5.7% vs 5.9% P=0.77). The primary and secondary outcomes did not differ among men and women with nonobstructive CAD (OR 1.79 P=0.46 and OR 3.27 P=0.26 respectively). Sex specific regression models of obstructive versus nonobstructive CAD showed that older age (OR 1.20 CI 1.04-1.39) only predicts significant CAD in men whereas current smoking (OR 2.19 CI 1.15-4.17) and diabetes (OR 3.57 CI 1.49-8.53) were only significant predictors in women. The relative risk of hypercholesterolemia was similar in men (OR 2.01 CI 1.38-2.92) and women (OR 1.92 CI 1.05-3.51). The risk of death among women with obstructive CAD was most pronounced than their male counterpart (OR 1.45 CI 1.03-2.06) Conclusions: Women have a higher risk of death after STEMI in comparison with men only in patients with obstructive CAD. Development of obstructive CAD is, therefore, the most serious and life-threatening event in women. Diabetes and current smoking were found to have a greater impact on development of obstructive CAD in women compared with men. Prevention of traditional risk factors is a major need for improving cardiovascular health among women. [ABSTRACT FROM AUTHOR]