STEMI risk increasing in younger women
September 03, 2013
Christopher Cannon, M.D., FACC, FSCAI
Director interventional cardiology
Providence Medical Group-Cardiology, Southern Oregon
Denise suffered her heart attack on Memorial Day after attending a family picnic. At only 37 years old, she could not believe that the burning sensation in her chest and vomiting were signs of a heart attack, and initially treated her discomfort with ibuprofen. She had had similar pain one day earlier, but these symptoms resolved. On the day of her heart attack, her symptoms only worsened with time, and she reluctantly came to the emergency department for evaluation.
An EKG indicated that she was having an acute inferior ST elevation myocardial infarction (or STEMI), and she was taken immediately to the cardiac catheterization laboratory. There, she was found to have a critical blockage in her right coronary artery. This was quickly opened and a stent placed. Fortunately for Denise, there was minimal damage and her heart function remained normal. After recovery, she was discharged to home, and has enrolled in the outpatient cardiac rehabilitation program.
A recent presentation at EuroPCR, a meeting of the European Association of Percutaneous Cardiovascular Interventions, shed light on what appears to be a growing problem of STEMI in women, and particularly younger women. Under-treatment and delays in treatment in women with heart attacks has long been recognized, although solutions to this problem have been slow in coming. Now, however, there is data suggesting that STEMIs in younger women are increasing.
According to data published in JAMA in 2012, the proportion of women suffering from acute heart attacks who presented without chest pain was significantly higher at 42 percent than for men (31 percent). This difference seemed to be more pronounced with younger women, who were even more likely to present without typical chest pain than were older women. When younger women do present without chest pain, their mortality is significantly higher than for men in the same age groups.
Additionally, 25 percent of women who have STEMI are under the age of 60, up from 12 percent in 1995. The number of MI in women under 50 increased even more quickly, up from 3 percent of women with MI in 1995, to 11 percent in 2010, based on data from France.
Risk factors that seem to be more uniform among younger patients who have heart attacks include obesity, smoking and dyslipidemia. Data from a registry in Michigan examining nearly 7,000 patients with STEMI show that smoking in particular seems to play a larger role in STEMI among younger people, The odds of a person under the age of 35 presenting with a myocardial infarction being a smoker is 11-fold higher.
While smoking remains an important risk factor in older patients, the prevalence of smoking gradually declines over time in older patients. In the French study mentioned above, the most significant factor in these younger women appeared to be smoking. It was noted that while the risk of obesity in younger women with MI appeared to be increasing, the chances these women being smokers was much higher.
Atherosclerotic heart disease and resulting myocardial infarction seems to be increasingly seen in younger women, but it is important to be aware of other, less common causes of acute heart attacks in women. There is a higher risk of spontaneous coronary dissection in women, and with a significant number of these occurring during pregnancy. Similarly, coronary vasospasm and vasculitis, lupus or other connective tissue diseases contribute to a higher risk of MI at a younger age.
Symptoms of STEMI in women have long been recognized to be less typical than in males. While chest pain, and heaviness, the proverbial “elephant on my chest” is more common in men, women are less likely to have these telltale signs. Shortness of breath, nausea and vomiting or flu-like symptoms: squeezing, fullness, or pain in the center of the chest; pain into one or both arms, back, neck, jaw or stomach may be signs of heart attack in women. Fatigue that is new or sudden may be another symptom.
Many women appear to be getting the message that their symptoms of a heart attack may be different than for a man. I have women in my practice who are able to relate that they have heard about these differences. However, many women still resist seeking medical care when they feel these symptoms. To add insult to injury, there has been a tendency for health care professionals not to recognize or underappreciate the signs and symptoms of heart disease in women, leading to further delays in appropriate care. These delays in recognizing symptoms and providing rapid lifesaving treatment, in part result in women having a higher risk of dying with myocardial infarction than men.
In Denise’s case, her heart attack was a wakeup call. She knew before the heart attack that she should stop smoking, that she really needed to lose weight and that her cholesterol was higher than it should be. She had no regular exercise routine, although she was very active. Unfortunately it took a STEMI to provide the motivation for her to finally come to grips with these things.
During her post-MI education while still in the hospital, she learned that quitting smoking alone could lower her risk of having another heart attack by 50 percent. She resolved to exercise, and began a cardiac rehab program where she began exercising in a safe, supervised setting. She later added swimming to her exercise routine.
She learned principles of healthier eating, and the importance of compliance with medical therapy, including statin use and beta blocker therapy post-MI. She relates that she feels better now then she did for years before her heart attack because of changes she has made to her lifestyle.
There is cause for both hope and concern when looking at data regarding young women and heart attacks. While things have turned out well for Denise, it is critical for those of us on the front lines of caring for patients to increase the awareness of the difference in symptoms of heart disease in women.
It is also critical to be aware of other causes of acute heart attacks. We must emphasize the need for women to take their symptoms seriously, and not delay seeking care. We must be vigilant to the signs and symptoms of STEMI in women, and not delay prompt diagnosis and early life-saving treatment.
Canto, JG, et al. "Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality"; JAMA Feb. 22, 2012; 307(8): 813-22
Stiles, S. "Smoking a bigger player in STEMI for younger patients"; Theheart.org. May 31, 2013
Wood, S. "Girl Trouble: Rising tide of STEMI in young women 'clearly not acceptable'”' Theheart.org. May 22, 2013
Szabo, L. "Women less likely to get immediate heart attack treatment"; USA Today. Feb. 21, 2012
Larsen GK, Seth M, Gurm HS. "The ongoing importance of smoking as a powerful risk factor for ST-segment elevation myocardial infarction in young patients"; JAMA Intern Med 2013; DOI:10.1001/jamainternmed.2013.6075