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February 21, 2012 (Lakeland, Florida) — Women under 55 having an MI are more likely to present without chest pain than older women or men, and they also have the highest risk of death from MI of any group, new data from the US National Registry of Myocardial Infarction (NRMI) suggest [1].
Lead author Dr John Canto (Lakeland Regional Medical Center, FL) commented: "While chest pain is still the hallmark symptom of MI in women, more women than men present without chest pain, and this is particularly applicable to younger women. We need to be more aware that younger women with atypical symptoms could be having a MI."
Canto's study, published in the February 22/29, 2012 issue of the Journal of the American Medical Association, used the NRMI database to examine the factors associated with MI without chest pain and the relationship between age, sex, and hospital mortality.
Canto told heartwire : "While it has been widely reported that women often have a different MI presentation from that of men, we also know that women are an average of 10 to 15 years older than men when they have an MI. Many papers that have examined the gender differences in MI presentation have failed to adequately account for this age difference. We had an opportunity to look at this more thoroughly in the NRMI database, which includes around one million MI patients."
They found that women are more likely to present without chest pain than men (42% vs 30%), but that this difference is more pronounced in younger women (under 55). The difference in symptoms at presentation between men and women declined with age, and in the older patients (over 75) there was little difference between the genders.
Adjusted Odds Ratios for Lack of Chest Pain for Women vs Men
| Age | OR |
| <45 | 1.30 |
| 45–54 | 1.26 |
| 55–64 | 1.24 |
| 65–74 | 1.13 |
| >75 | 1.03 |
The second major finding of the study was that younger women having an MI have a higher mortality rate. "Younger women are not supposed to have an MI, but when do, they are at higher risk of death than the rest of the population," Canto commented.
In the registry, the in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age.
Adjusted Odds Ratio for Death After an MI in Women Without Chest Pain vs Men Without Chest Pain
| Age | OR |
| <45 | 1.18 |
| 45–54 | 1.13 |
| 55–64 | 1.02 |
| 65–74 | 0.91 |
| >75 | 0.81 |
The researchers also found that young women without chest pain were up to two to three times more likely to die than similarly aged men with classic presentation.
They write: "Women in whom coronary atherosclerosis develops before age 75 years may be predisposed to a particularly aggressive disease or may have more risk factors for coronary heart disease, which might override the protective effect of estrogen." They add that young women who die after an MI are often smokers with plaque erosions and relatively little coronary narrowing, whereas older women who die tend to have a pathology more similar to men, with high cholesterol levels and subsequent plaque rupture and relatively severe coronary narrowing.
Canto also suggested that the higher likelihood of atypical symptoms in younger women could contribute toward their high death rate. "If a young women presents without chest pain, it is easy not to realize that she is having an MI. Triage staff are less likely to think about MI in a younger woman, especially one without chest pain, so there is a higher probability of not receiving timely treatment. This could easily explain some of the increased mortality in this group."
He added: "Our results challenge the wisdom that one size fits all in terms of men and women and presenting MI symptoms. I would argue that we need to tailor the MI message and that young women are particularly at risk for an atypical presentation." Canto noted that the atypical symptoms of MI include pain in the jaw, neck, shoulder, arm, back, or stomach and unexplained shortness of breath.
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