Younger women more likely than men to experience MI without chest pain

Canto JG. JAMA. 2012;307:813-822.

In a study involving more than 1 million patients, researchers found women with myocardial infarction were more likely to present without chest pain and had higher mortality compared with men. These differences, however, became less pronounced with increasing age.

Researchers collected and analyzed hospital data from the National Registry of Myocardial Infarction on 1,143,513 patients (42.1% women) admitted with confirmed MI from 1994 to 2006. The presence or absence of chest pain/discomfort was the only symptom recorded. Main outcome measures included predictors of MI without chest pain and the relationship between age, sex and hospital mortality.

Researchers found a significant interaction between sex and age with chest pain at presentation (P<.001). The proportion of women who presented without chest pain (42%; 95% CI, 41.8-42.1) was higher when compared with men (30.7%; 95% CI, 30.6-30.8). This difference was larger in younger patients; however, the difference decreased with advancing age. For lack of chest pain in women, multivariable adjusted age-specific ORs were: 1.30 (95% CI, 1.23-1.36) for age younger than 45 years; 1.26 (95% CI, 1.22-1.30), 45 to 54 years; 1.24 (95% CI, 1.21-1.27), 55 to 64 years; 1.13 (95% CI, 1.11-1.15), 65 to 74 years; and 1.03 (95% CI, 1.02-1.04), 75 years or older.

The interaction between sex, age and presentation without chest pain was also significant for mortality, with 14.6% of women and 10.3% of men experiencing in-hospital mortality. According to study results, among MI patients presenting without chest pain, younger women had greater hospital mortality vs. younger men. However, adjusted ORs showed these sex differences decreased or even reversed with advancing age: 1.18 (95% CI, 1.00-1.39) for age younger than 45 years; 1.13 (95% CI, 1.02-1.26), 45 to 54 years; 1.02 (95% CI, 0.96-1.09), 55 to 64 years; (95% CI, 0.88-0.95), 65 to 74 years; and 0.81 (95% CI, 0.79-0.83), 75 years or older.

The researchers said to enhance the current understanding of underlying pathophysiology and potentially sex-tailored health messages to the general public, further research is warranted.

“Our results of sex-based differences in MI symptom presentation in younger patients are provocative and should be confirmed by others with clinical databases of MI or acute coronary syndromes,” the researchers said. “From a public health perspective, it is appropriate to target high-risk groups for delay with information on the American Heart Association/NIH MI message, but until additional research is conducted, the current chest pain/discomfort MI symptom message, which targets women and men equally irrespective of age, should remain unchanged.”

Disclosure: Mr. Frederick reports being an employee of ICON Clinical Research. Dr. Peterson reported receiving research grants from Bristol-Myers Squibb, Eli Lilly, Johnson & Johnson, Sanofi-Aventis, Schering Plough/Merck and St Jude Inc., and consultant fees from Bayer and Pfizer. Dr. Wenger reported receiving research grants and/or trial committee or data and safety monitoring board compensation from Abbott, Eli Lilly, Gilead Sciences, Merck, NHLBT and Pfizer; she also reported receiving consultant fees from Abbott Women’s Advisory Board, AstraZeneca, Gilead Sciences, Merck and Pfizer.

Roxana Mehran, MD
Roxana Mehran

The profound finding of this study is the demographics of the women presenting with or without chest pain with acute MI. We’ve already known that women present with atypical or no chest pain whatsoever, but the critical finding of this study is that these younger women who presented with no chest pain actually had the highest mortality. There was also an important age and sex interaction with the symptoms of presentation at the time of acute MI; such that the younger women presented without chest pain more often than men. As women aged, that difference no longer existed. Having said that I think we shouldn’t forget that the prevalence of coronary disease is increased with increasing age in the female sex. We already know that the younger women present with more co-morbidities including diabetes mellitus. Hopefully this study will be a wakeup call for a lot of physicians, especially in the ED to improve the time to treatment for acute myocardial infarction especially in the younger women, because the longer the time before women are evaluated and given the proper treatments the higher the mortality.

– Roxana Mehran, MD, FACC, FSCAI, FAHA
Director of Interventional Cardiovascular Research
Cardiovascular Institute, Mount Sinai School of Medicine

Disclosure: Dr. Mehran reports no relevant financial disclosures.

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