We conducted a retrospective cohort study based on a case note review to determine whether there are differences in the treatment pathways followed for men and women admitted with acute myocardial ischemia and infarction after adjusting for differences in case mix. Women were as likely as men to receive thrombolysis, but were less likely subsequently to undergo exercise testing (adjusted odds ratio, 0.58; 95% CI, 0.40-0.84) or angiography (adjusted odds ratio, 0.62; 95% CI, 0.39-0.99). Coronary anatomy was the strongest predictor of revascularization regardless of sex. Women with diagnosed cardiac pain are less likely than men to be placed on the investigative pathways that lead to revascularization. Those women who are investigated are as likely as men to undergo revascularization. These findings are independent of the effects of age, angina grade, comorbidity, or cardiac risk factors. Clinicians' and patients' beliefs and preferences about treatment require investigation.