Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality.
Level 3 - non-randomized controlled study
Retrospective registry-based observational cohort study
PubMed 22357832 · doi:10.1001/jama.2012.199
What was done
This was an observational cohort study utilizing data from the National Registry of Myocardial Infarction (1994–2006) including 1,143,513 patients (481,581 women and 661,932 men) hospitalized with myocardial infarction (MI). The authors evaluated predictors of MI presentation without chest pain and examined the associations and interactions between sex, age, symptom presentation, and in-hospital mortality.
What was found
A higher proportion of women presented without chest pain compared to men (42.0% [95% CI, 41.8%–42.1%] vs 30.7% [95% CI, 30.6%–30.8%]; P < .001). The sex gap was largest in younger cohorts and attenuated with age; multivariable-adjusted odds ratios (ORs) for lack of chest pain in women (referent: men) were 1.30 (95% CI, 1.23–1.36) for age <45 years, 1.26 (95% CI, 1.22–1.30) for 45–54 years, 1.24 (95% CI, 1.21–1.27) for 55–64 years, 1.13 (95% CI, 1.11–1.15) for 65–74 years, and 1.03 (95% CI, 1.02–1.04) for >=75 years (sex-age interaction P < .001). Overall in-hospital mortality was 14.6% in women and 10.3% in men. Among patients presenting without chest pain, younger women experienced higher adjusted mortality than younger men, but this pattern reversed in older age groups: adjusted ORs for mortality in women vs men were 1.18 (95% CI, 1.00–1.39) for age <45, 1.13 (95% CI, 1.02–1.26) for 45–54, 1.02 (95% CI, 0.96–1.09) for 55–64, 0.91 (95% CI, 0.88–0.95) for 65–74, and 0.81 (95% CI, 0.79–0.83) for >=75 years (3-way interaction P < .001).
Why it matters
These findings establish that the risk of atypical presentation without chest pain and associated excess mortality in women with MI is heavily age-dependent, highlighting that younger women are at the greatest relative disadvantage.
Limits
The study is observational and restricted to hospitalized patients in a voluntary registry, which may introduce selection bias. Pre-hospital deaths and out-of-hospital presentations were not captured, and unmeasured clinical confounders or differences in acute treatment delivery may have contributed to mortality differences.
Cited by
- context During heart attacks, chest and arm pain are less common in women than in men, while shortness of breath is more common in women.