Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality

Study Questions:

What are the associations between age, symptom presentation, and sex among patients with myocardial infarction (MI)?


This is an observational study using data from the National Registry of Myocardial Infarction (NRMI), an industry-sponsored registry of 2,160,671 patients admitted with a confirmed MI from 1,977 participating hospitals between 1994 and 2006. Patients who were transferred from another institution or with a secondary diagnosis of MI were excluded, as were patients with missing information on age, sex, or presenting symptoms, leaving a final study population of 1,143,513 patients. The primary outcome of interest was predictors of MI among patients who did not experience chest pain.


Among the cohort of 481,581 female and 661,932 male registry patients, the proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0%; 95% confidence interval [CI], 41.8%-42.1% vs. 30.7%; 95% CI, 30.6%-30.8%; p < 0.001). Women were significantly older than men at time of presentation (73.9 years vs. 66.5 years, p < 0.001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable-adjusted age-specific odds ratios for lack of chest pain for women were: younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45-54 years, 1.26 (95% CI, 1.22-1.30); 55-64 years, 1.24 (95% CI, 1.21-1.27); 65-74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (p < 0.001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45-54 years, 1.13 (95% CI, 1.02-1.26); 55-64 years, 1.02 (95% CI, 0.96-1.09); 65-74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The three-way interaction (sex, age, and chest pain) on mortality was significant (p < 0.001).


The investigators concluded that among patients admitted with MI, women were more likely to present without chest pain symptoms. Women also had higher mortality than men within the same age groups.


These data support prior studies, which have observed that women are more likely to present with atypical symptoms, as opposed to chest pain.

Keywords: Myocardial Infarction, Hospital Mortality, Chest Pain, Phenotype, Cardiovascular Diseases

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