Heart Disease: Does Sex Matter?

If a tree falls in a forest and no one is around to hear it, does it make a sound?  Likewise, can someone have a heart attack without suffering from crushing substernal chest pain?  As most physicians know, many (female) patients with acute coronary syndrome (known as a heart attack in laymen's terms) don't present to their physician or emergency department clutching their chest exclaiming Redd Foxx's classic "Elizabeth, it's the big one", as made famous in Sanford & Son.

In a cohort study addressing this question published last week in JAMA, the authors evaluated the outcomes of 1,143,513 patients, of whom 481,581 were female, who participated in an observational registry.  Of note, women were more likely to present without complaining of chest pain (42%) and were more likely to die (14.6%) compared to men in a similar age group (30.7% & 10.3%, respectively).  The good news is that the difference in presentation & mortality was less problematic with advancing age.

A different perspective of Venus vs Mars was published almost 3 years ago in JAMA when authors performed a meta-analysis of 11 independent randomized trails involving 136,247 patients, of whom 38,048 were female.  They initially concluded that women were almost twice as likely to die within the first month post-infarct compared to men (9.6% vs 5.3%).  The findings were not thought to be statistically significant after taking into account the usual confounders.  However, when looking specifically at ST elevation myocardial infarction (STEMI), women were 15% more likely to die within the first month.  A subgroup of women underwent angiography and demonstrated more non-obstructive and less 2- & 3-vessel disease compared to their male cohorts.  After taking into account this difference in angiographic data, there was no difference in 30 day mortality between men & women.  

So what are we to make of these two studies?  The authors stated that despite differences in presentation, no change to the public health message regarding chest pain & discomfort (regardless of sex & age) should be made at this time.  However, as we come to the end of yet another American Heart Month, I would posit that perhaps we should be more suspicious for heart disease in our younger female patients.

Follow @alvinblin
Tweet