Women who have a heart attack at a younger age tend to have worse outcomes and are more likely to return to the hospital than their male counterparts.
More significant underlying risk factors could be why, according to new research.
Researchers called for greater public awareness around heart attacks in young women, including the unique symptoms they experience and the care they need. Their findings were published in the Journal of the American College of Cardiology.
"This all begins with public awareness towards preventing heart attacks and screening programs to detect traditional risk factors before a patient has a heart attack. Many people think heart attacks only occur in middle-aged or older men, which is not true," said lead author Dr. Mitsuaki Sawano, a postdoctoral associate at Yale-New Haven Hospital Center for Outcomes Research and Evaluation in New Haven, Conn.
"People need to be aware that heart attacks occur in young women as well and they can present with atypical symptoms," Sawano said in a journal news release.
A second heart attack and heart-related chest pain were reasons women returned to the hospital after their initial heart attack.
The greatest disparities, however, were seen in non-cardiac hospitalizations, according to the study.
Using data from a heart attack study of 18- to 55-year-olds, researchers looked at issues that required hospitalization for more than 24 hours within a year of the heart attack.
The study included more than 2,000 women and nearly 1,000 men.
Patients were hospitalized for recurrent heart attack or chest pain due to the heart; heart failure; arrhythmias; valve disease, and stroke. They were also hospitalized for unrelated issues, including gastrointestinal problems, bleeding and psychiatric conditions.
Sawano said researchers think young women who present with heart attacks have a greater burden of risk factors compared with men.
"In general, young, premenopausal women are protected by their own estrogen hormone to have lower incidence of heart attacks," he said. "Thus, to overcome this physiological protection, we think a higher accumulation of risk factors, such as obesity, high blood pressure, high cholesterol, cigarette smoking, etc., is needed to cause a 'breakthrough' effect."
The patients had an average age of 47. About 70% were white. More women than men were Black.
The women also had more obesity, congestive heart failure, prior stroke and kidney disease. They were more likely to be low-income, have a history of depression and have significantly worse health status compared to men in the study.
"For women, this greater number of risk factors are likely to cause difficulty controlling them after discharge," Sawano said. "Worse control of risk factors is associated with worse outcomes, including recurrence of heart attacks, chest pain due to the heart, as well as other atherosclerotic diseases like stroke."
Among the cases in the study, women were less likely to have chest pain when they arrived at the hospital and more likely to arrive more than six hours after their symptoms began.
They were also more likely to have what's called a non ST-elevated myocardial infarction, a heart attack that happens when the heart's need for oxygen is not met. They were also more likely to have a myocardial infarction with nonobstructive coronary arteries (MINOCA), a heart attack not caused by a blockage.
The women experiencing MINOCA were younger, more likely to be Black, to be smokers, to have lower education status and to have the lowest proportion of previous coronary artery disease.
These women also tended to stay in the hospital longer and receive lower rates of recommended medical therapies, such as aspirin, statins, beta-blockers and angiotensin-converting enzyme inhibitors (ACE inhibitors).
They were also less satisfied with their treatment than patients who had myocardial infarction with obstructive coronary artery disease (MI-CAD).
The study found that all-cause hospitalization rates within one year of discharge were 34.8% for women and 23% for men. The leading cause of hospitalizations for women was heart-related.
"We think that the accumulation of risk factors seen in the MI-CAD population is associated with the high incidence of hospitalization one year after heart attack," Sawano said. "We must emphasize, however, that does not mean that MINOCA patients are 'low risk.' "
The authors said the findings show a need for secondary preventive strategies to reduce coronary-related hospitalizations and to further research the causes of non-cardiac hospitalization.
In an accompanying editorial, Dr. Martha Gulati, director of preventive cardiology at Cedars-Sinai in Los Angeles, said the cause of sex differences is elusive.
"Why are more women than men identified as low-income in this cohort? Why does this cohort demonstrate a nearly twofold greater prevalence of depression in women as compared to men? As a cardiovascular community, by continuing to ask why perhaps we can arrive at 'what next,'" Gulati wrote.
The American Heart Association has more on heart attack symptoms in women.
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