Premenopausal Women Demonstrate Better Long-Term Heart Attack Outcomes

Diego Ardissino, MD

A new study presented at the European Society of Cardiology (ESC 2020) Congress demonstrated that premenopausal women have better long-term outcomes after a heart attack than older women.

Although previous research has suggested that women are at a greater mortality risk following a heart attack than men, emerging data shows that the hormone estrogen has a protective, anti-heart attack effect in women who have not undergone menopause.

The Italian Genetic Study on Early-onset Myocardial Infarction, led by Diego Ardissino, MD, Director of the Cardiology Complex at the University Hospital of Parma, Italy, enrolled 2000 patients—1778 men vs 222 women—who had experienced a myocardial infarction in-hospital prior to age 45.

The study’s data was drawn from 125 italian care units between 1998 and 2002.

The investigators sought primary endpoints in the composite of recurrent heart attack, stroke, or death from cardiovascular (CV) disease. Furthermore, they compared these outcomes between the sexes.

When they conducted a median follow-up of 20 years, they found that the primary composite endpoints had occurred in 25.7% of women—versus 37.0% in men (HR, .69; 95% CI, 0.52-0.91; P = .01).

Recurrent heart attacks occurred less frequently in women compared to men (14.2% vs 25.4%, respectively; HR, .53; 95% CI, 0.37-0.77; P<0.001).

Conversely, the occurrence of stroke was higher in women (7.7% vs. 3.7% men; HR, 2.02; 95% CI, 1.17-3.49; p = .012).

Men had higher reported frequencies of smoking (46.5% vs 42.8% women), alcohol consumption. (65.3% vs 27.4%), high blood lipids (62.3% vs 50.7%), and diabetes (7.8% vs 5.4%; P<.001).

Ardissino noted that the different mechanisms behind the heart attack had a likely association with this discrepancy in prognosis between the sexes.

“In men, coronary events were mostly due to blocked arteries, while in women they had other causes such as coronary dissection which is known to have a more favorable prognosis and a lower risk of recurrence,” he said in a press statement.

Women were much likelier to have heathier arteries versus men (36.5% vs 15.4%, P<.001), but a greater frequency of coronary artery dissection (5.4% vs 0.7%, P<.01).

The investigators noticed that men were likelier than women to be prescribed medications to protect against a recurrent heart attack—such as beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers.

And finally, men and women were similarly likely to receive statin treatment.

According to Ardissino, the disparity in prescribing may have an association to the younger female population’s overall lower burden of coronary artery disease (CAD. Additionally, it may also point to the general under-prescribing of medications in women that had been noted in other studies related to acute cardiac events.

“In contrast to the prevailing literature, women experiencing an early-onset heart attack have favorable long-term outcomes compared to men, despite being prescribed fewer preventive medications,” Ardissino concluded.

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