Women With Heart Attack More Likely Than Men To Present Without Chest Pain and Have Higher In-Hospital Mortality



Among heart attack patients, women are more likely than men to present to a hospital without chest pain and also have a higher rate of in-hospital death following a heart attack than men within the same age group, although these differences decrease with increasing age, according to a study in the February 22/29 issue of JAMA.

“Optimal recognition and timely management of myocardial infarction [MI; heart attack], especially for reducing patient delay in seeking acute medical care, is critical. The presence of chest pain/discomfort is the hallmark symptom of MI,” according to background information in the article. Despite this well-accepted symptom, previous analyses have shown that a large number of patients with MI lack chest pain/discomfort at presentation. “Furthermore, patients without chest pain/discomfort tend to present later, are treated less aggressively, and have almost twice the short-term mortality compared with those presenting with more typical symptoms of MI.”

The authors add that women are generally older than men at hospitalization for heart attack. “It is plausible that women's older age at presentation is related to whether they present with chest pain, as well as subsequent hospital mortality. However, a limited number of studies have taken age into account in examining sex differences in MI clinical presentation.”

John G. Canto, M.D., M.S.P.H., of the Watson Clinic and Lakeland Regional Medical Center, Lakeland, Fla., and colleagues examined the relationship between sex, symptoms when presenting to the hospital, and the risk of death while in the hospital, before and after accounting for age in patients hospitalized with MI. The study consisted of an analysis of data from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients. Of these, 42.1 percent were women. Women with MI were significantly older than men at hospital presentation, with an average age of 74 years, vs. 67 years for men.

The overall proportion of MI patients who presented without chest pain/discomfort was 35.4 percent and was significantly higher for women than men (42.0 percent vs. 30.7 percent). Age-specific and further analyses indicated a significant interaction between age and sex, with sex-specific differences in MI presentation without chest discomfort becoming progressively smaller with advancing age.

The in-hospital mortality rate was 14.6 percent for women and 10.3 percent for men. The researchers found that in the fully adjusted models, younger women presenting without chest pain/discomfort had greater hospital case-fatality rates than men, a trend that reversed with increasing age. “However, younger women presenting with chest pain/discomfort had a greater hospital case-fatality rate than men with chest pain/discomfort in the same age group, but differences in hospital death rates between men and women decreased with advancing age (no longer significant in the oldest group),” the authors write. “These data suggest that the absence of chest pain may be a more important predictor of death in younger women with MI compared with other similarly aged groups.”

The authors add that further research is needed to improve the current understanding of underlying pathophysiology and potentially sex-tailored health messages to the general public and health care providers to encourage men and women with signs and symptoms of acute coronary syndromes to seek care promptly, which will result in improvement in the care and survival of women. “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. From a public health perspective, it is appropriate to target high-risk groups for delay (young women) with information on the American Heart Association/National Institutes of Health heart attack message, but until additional research is conducted, the current chest pain/discomfort heart attack symptom message, which targets women and men equally irrespective of age, should remain unchanged.”

(JAMA. 2012;307[8]:813-822.