Acute Myocardial Infarction in Women: AHA Statement

Mehta LS, Beckie TM, DeVon HA, et al.
Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation 2016;Jan 26:[Epub ahead of print].

The following are key points to remember from an American Heart Association Scientific Statement about acute myocardial infarction (AMI) in women:

  1. Cardiovascular disease (CVD) is a leading cause of mortality among women. Since 1984, CVD mortality is higher in women than men. However, declines in CVD mortality among women have been observed in the past 2 decades, likely due to improved receipt of evidence-based therapies, and increased awareness of heart disease among women. Yet gaps in current management and understanding of AMI among women remain.
  2. In the 12 months following AMI, women are more likely to die than men. Rates of heart failure and stroke are also elevated for women. This may in part be due to increased rates of risk factors including diabetes, heart failure, hypertension, depression, and renal dysfunction. Women are more likely to experience non–ST-segment elevation MI, spontaneous coronary dissection, and coronary artery spasm as compared to men.
  3. Younger women remain at increased risk for death after AMI. Given the recent increase in coronary heart disease events among women 45-65 years of age, these trends are concerning. Research related to the age–gender relationship should include sex-specific biology, clinical manifestations, and an improved understanding of the environmental and social factors that may increase risk among younger women.
  4. Race/ethnicity are also important factors to be examined in relation to AMI in women. Black women have a higher prevalence of AMI than other women, including higher rates of sudden cardiac death. Asian Indian women also have higher mortality rates, which may be associated with higher rates of CVD risk factors.
  5. AMI pathophysiology may also differ among women compared to men. Men have higher rates of plaque rupture in the setting of AMI, while for women, plaque rupture accounts for approximately 55% of AMI. Plaque erosion is more common in women than man, in particular younger women. Spontaneous coronary artery dissection is a rare cause of AMI, found more often among women than men, particularly among young women.
  6. CVD risk factors are similar for both men and women; however, the potency of risk factors may differ. Data from the INTERHEART study suggest that 96% of population-attributable MI risk for women is related to smoking, hypertension, diabetes, central adiposity, diet, physical activity, alcohol consumption, lipids, and psychosocial factors, many of which are modifiable. Smoking may have a stronger MI risk for women compared to men. Hypertension is also a major risk factor for women. Low high-density lipoprotein (HDL) cholesterol, elevated triglycerides, obesity, and diabetes—all of which frequently occur together—increase a woman’s risk for AMI.
  7. Symptom presentation in the setting of AMI differs for men and women. Although most patients present with typical chest pain, including women, women are more often reporting atypical chest pain and/or associated symptoms (dyspnea, fatigue, weakness) compared to men. This may account for greater treatment delays observed in women compared to men.
  8. Management of AMI also differs among men and women. Thrombolytic therapy is recommended for both men and women in the setting of AMI for those who present to a non-percutaneous coronary intervention (PCI)-capable hospital when delay to performing PCI is estimated to be >120 minutes. However, women have a greater bleeding risk compared to men. Use of primary PCI for women experiencing AMI lowers risk of bleeds such as intracranial hemorrhage, yet other types of bleeds are still higher among women than men.
  9. Recommendations for medical therapy after AMI are similar for women and men, including beta-blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers, antiplatelet agents, and statins. Careful monitoring of weight and renal function may lower a woman’s bleeding risk related to antiplatelet therapy. Nonselective beta-blockers should be used when coronary vasospasm is suspected. ACE inhibitors and statins are to be avoided during pregnancy. Yet there is ample evidence to suggest that receipt of such medications is lower among women than men.
  10. Recommendations to improve management of AMI in women include the correction of under-representation of women in clinical trials. Data presented with sex- and gender-specific results are currently lacking in many studies. Research gaps exist related to coronary pathophysiology, optimal diagnostic testing (including imaging), optimal pharmacologic and interventional strategies, and the understanding of race/ethnicity, socioeconomic, and psychological factors. Thus, women’s cardiovascular health requires a multidisciplinary approach to both research and clinical activities.

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