Young Women At Greater Mortality Risk Following Heart Attack than Young Men

Ron Blankstein, MD

An analysis of more than 2000 patients treated at Brigham and Women’s Hospital and Massachusetts General Hospital suggests young women were 1.6 times more likely than men to die in the first 11 years following a heart attack.

Results of the study, which investigators claim is the first to investigate these outcomes in such an extensive follow-up period, indicate young women were less likely to undergo therapeutic invasive procedures after admission to hospital with a heart attack or to be prescribed certain medical therapies, such as ACE inhibitors or statins, at discharge.

"It's important to note that overall most heart attacks in people under the age of 50 occur in men. Only 19% of the people in this study were women,” noted Ron Blankstein, MD, professor of medicine at Harvard Medical School and a preventive cardiologist at Brigham and Women’s Hospital, in a statement. “However, women who experience a heart attack at a young age often present with similar symptoms as men, are more likely to have diabetes, have lower socioeconomic status and ultimately are more likely to die in the longer term."

With a knowledge gap existing in regard to sex differences in outcomes following myocardial infarction in younger patients, Blankstein and a team of colleagues sought to examine potential differences in outcomes using data from the Partners YOUNG-MI registry, which contains information related to adult patients aged 50 years or less presenting with a first-time myocardial infarction at Brigham and Women’s or Massachusetts General Hospital from 2000-2016. From the registry, investigators obtained data related to a cohort of 404 women and 1693 men for inclusion in their analysis.

Patients included in the analysis were diagnosed with Type 1 myocardial infarction and were excluded if they had a previous diagnosis of coronary artery disease, which was defined as a prior myocardial infarction or revascularization. The median age of the study cohort was 45 (IQR, 41-48) years, 73% were white, and 53% were classified as having had a STEMI.

When comparing the 2 groups, investigators noted women were less likely than men to have a STEMI. While risk factor profiles were similar between the study arms, investigators also noted women had lower median income, were significantly more likely to have public insurance, and were more likely to have diabetes (23.7% vs 18.9%; P=.028) than their male counterparts.

Upon analysis, results indicated women were less likely to invasive coronary angiography (93.5% vs. 96.7%, P = 0.003) and coronary revascularization (82.1% vs. 92.6%, P < 0.001) than men. Additionally, women were significantly more likely to have myocardial infarction with a non-obstructed coronary disease on angiography (10.2% vs 4.2%; P <.001) and were less likely to be prescribed aspirin (92.2% vs 95.0%; P=.027), beta-blockers (86.6% vs 90.3%; P=.033), ACEs/ARBs (53.4% vs 63.7%; P <.001), and statins (82.4% vs 88.4%; P <.001) at discharge than their male counterparts.

While results of the analysis indicated there were no significant differences in in-hospital mortality, women who survived to hospital discharge experienced a greater rate of all-cause mortality (aHR, 1.63; P=.01) with no significant difference in cardiovascular mortality (aHR, 1.14; P=.61).

Investigators pointed out multiple limitations within their study for clinicians to consider to avoid overinterpretation of study results. Among these were inability to account for potential confounders impacting patient outcomes or management, lack of data related to medication adherence, and the potential for the small number of women included to have an impact on results.

In an accompanying editorial, Marysia Tweet, MD, assistant professor of medicine at the Mayo Clinic College of Medicine and Science in Minnesota, notes the importance of aggressive treatment of cardiovascular risk factors in young populations, particularly women.

“This study… demonstrates the continued need—and obligation—to study and improve the incidence and mortality trajectory of cardiovascular disease in the young, especially women,” wrote Tweet. “We can each work towards this goal by increasing awareness of heart disease and 'heart healthy' lifestyles within our communities; engaging with local policy makers, promoting primary or secondary prevention efforts within our clinical practices; designing studies that account for sex differences; facilitating recruitment of women into clinical trials; requesting sex-based data when reviewing manuscripts; and reporting sex differences in published research."

This study, “Women who experience a myocardial infarction at a young age have worse outcomes compared with men: the partners YOUNG-MI registry,” was published in the European Heart Journal.