Rates of total and unrecognized myocardial infarction (MI) have decreased from the 1990s to the 2010s, according to an analysis of the Rotterdam Study published recently in JAMA Cardiology. Nevertheless, Julie Anne Eni van Oortmerssen, MD, MSc, et al., maintain the importance of continued efforts to identify unrecognized MI.

The Rotterdam Study covered three decades: 1990s (n=7,750), 2000s (n=7,675) and 2010s (n=7,121). Forty-two percent of participants were men. MI status was based on electrocardiogram (ECG) results and medical records and was classified as unrecognized MI, recognized MI or no MI.

Results showed a decrease in unrecognized MI as well as total MI across the three decades (1990s: 5% and 12.3%; 2000s: 4.3% and 11.2%; 2010s: 1.5% and 7.2%, respectively). Disparities in detection of MI in women vs. men were noted by the authors, with the proportion of unrecognized MI relative to total MI higher among women (overall: 52% vs. 25%).

Additionally, participants with unrecognized MI did not report more chest pain than those without MI (30% vs. 31%, respectively). Participants with recognized MI reported the symptom more frequently (75%). "Further research is needed to establish whether unrecognized MI is truly silent or related to recognition issues, health care access and health care-seeking behavior," write the authors.

Study limitations were also noted, including unrecognized MI diagnosis being based on ECG criteria, potential underreporting of symptoms, and the study population consisting predominantly of individuals with European ancestry, which could limit generalizability to other populations.

"The findings of van Oortmerssen and colleagues offer a valuable long-term perspective on how the epidemiological landscape of recognized and unrecognized MI has shifted over three decades," write Stephan Windecker, MD, and Robert A. Harrington, MD, MACC, in an accompanying editorial comment. "It also illustrates the limits of a single diagnostic era as ECG-based MI ascertainment is further complemented by biomarkers and cardiac imaging."