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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Women's Health
October 8, 1999

News this month
Heart attacks more deadly for women

New research shows heart attacks in women, particularly younger women, are considerably more likely to be fatal than those in men. Previous research has shown that overall women with heart attacks fare less well than men, and experts have speculated why this might be so. Some have attributed these differences to how male and female patients are treated or the presence of other diseases. While these factors may be part of the story, at this point, most of the differences in outcomes are unexplained. Researchers speculate unknown biological factors may increase the risk of women.

“Even though women under 50 get fewer heart attacks than men of the same age, they are twice as likely to die.”

The latest study shows the largest difference in mortality occurs in the youngest group of patients. Even though women under 50 get fewer heart attacks than men of the same age, they are twice as likely to die.

A second study published in the same July 22 issue of the New England Journal of Medicine also found that women with heart attacks were more likely than men to die. This research also suggests women’s heart attacks tended to have different causes than men’s and different symptoms. These atypical symptoms make a quick and accurate diagnosis trickier when women appear at the hospital.

National Registry Study
Yale University researcher Viola Vaccarino, MD, PhD, was the lead author of this study. She and her colleagues analyzed data of 155,565 women and 229,313 men who were enrolled in the National Registry of Myocardial Infarction 2 between June 1994 and January 1998. The subjects, who ranged between 30 and 89 years of age, had heart attacks and were treated at 1,658 hospitals.

Vaccarino and her co-authors found that overall, 11.5 percent of men and almost 16.7 percent of women, died during hospitalization for heart attacks. However, when they divided patients by age, the researchers found that the younger the women, the higher their risk compared with men. With every five-year decrease in age, women’s risk for death increased 7 percent relative to men’s. Women younger than 50 years had a mortality rate during hospitalization that was twice that of men their age–6.1 percent vs. 2.9 percent. The difference grew smaller with age; by age 75, the mortality rates were similar, at 18.4 percent among women and 19.1 percent among men.

Younger women were more likely than men their age to have other diseases, diabetes, a history of stroke and congestive heart failure. Women of all ages were less likely to receive blood-thinning drugs and beta blockers in the first 24 hours; however, according to Dr. Vaccarino, "these explanations account for no more than one-third of the differences."

More research is needed to explain women’s higher risk and better ways to detect heart problems in younger women need to be found, according to Dr. Vaccarino. A likely key to sex-based differences in heart attack outcomes for younger women is estrogen. While the hormone normally spares young women from heart disease, Dr. Vaccarino said, young women with heart disease may have abnormalities in estrogen metabolism or in estrogen receptors.

Global Use of Strategies to Open Occluded Arteries Study
Dr. Judith Hochman, an investigator affiliated with St. Luke’s-Roosevelt Hospital Center in New York City, and her colleagues looked at 12,142 men and women with heart problems and found that overall women who sustained heart attacks were more likely to die than men. They were more likely to have weakened heart muscles, dangerously low blood pressure and electrocardiograms that made it difficult to tell if they were having a heart attack upon first examination.

“Women presenting with a heart attack or unstable angina, especially younger ones, may have normal EKGs.”

These differences illustrate the challenges in diagnosing women, according to Dr. Hochman. Women presenting with a heart attack or unstable angina, especially younger ones, may have normal EKGs. They are less likely to have heart attacks caused by a total blockage of an artery than were men. Total blockages produce a characteristic pattern on electrocardiograms that make diagnosing a heart attack more certain. Women have clearer arteries than men. Researchers suggest their heart attacks are probably caused by large blood clots and spasms in arteries.

Women also had more treatment complications, Dr. Hochman pointed out. Their risk for bleeding was higher than men’s, particularly among those with elevated blood pressure. Women may, according to Dr. Hochman, routinely receive drug doses too high for their body weight.


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Viola Vaccarino, M.D., PhD.

Research uncovers gender medical mystery

Heart disease takes the lives of more than 234,000 American women a year, more than any other disease, but young and middle-aged women and their physicians often minimize the threat of this disease and focus on cancer.

“We need to think about women and heart disease in a fundamentally different way.”

We’re learning that although younger women suffer fewer heart attacks than men their age, they are more likely to die. Younger women and their physicians need to be very aware of this risk. Our research indicates we need to think about women and heart disease in a fundamentally different way.

For many years, we have been trying to answer the question: "Do women die more often after heart attacks than men?" Over the last decade, there have been several studies that have looked at this issue. Some indicated women do die more often from heart attacks, but this difference can be attributed to older age and pre-existing diseases. Other studies found women do worse even when age and coexisting diseases are put into the mix. However, these studies did not examine different age groups separately.

Our very large patient sample made it possible for us to compare the data of men and women within five-year age categories. Our suspicion was that in the younger age categories, women do, in fact, fare worse than men the same age. And that’s what we found. Women younger than 50 are twice as likely to die from heart attacks than men their age. The difference diminishes as they age until about age 75 when men and women’s mortality rates merge.

Why the difference?
The question, of course, is why do younger women with higher estrogen levels that we usually consider protective from heart disease, do worse? There must be factors that we clearly don’t understand at this point. We looked at some possible explanations.

  • Women had other conditions that worsened their outlook compared to men such as diabetes, more history of stroke and congestive heart failure, but these differences only explained about 10 percent of the mortality difference.
  • Women tended to delay going to the hospital, and when they got there, they were not treated as aggressively with established treatments such as aspirin, beta-blockers and other blood-thinning drugs.

These differences, taken together, accounted for about one third of the difference in mortality rates.

We took into account everything we could, but the greater portion of the differences between younger men and younger women is still unexplained.

"Young women and health care professionals need to realize young women can develop heart disease, but their disease may not look the same as it does in men."

Knowledge is power
Young women and health care professionals need to realize young women can develop heart disease, but their disease may not look the same as it does in men.

First, younger women have fewer classic symptoms than men.

  • They are less likely to experience chest pains that signal the start of a heart attack. They are more likely to complain of shortness of breath, heart palpitations or back pain.
  • Women wait longer after the onset of symptoms to seek treatment, and when they do get to the emergency room, they have EKG readings that often fail to pick up the telltale signs of a heart attack.

Risk factors
So what can we do? We need to work on what we know to be risk factors such as high blood pressure, high cholesterol, family history, smoking, obesity and diabetes. The risk factors for heart disease are the same for men and women, although some of the risks are stronger indicators of the likelihood of developing disease in women than in men. For example, diabetes is a stronger risk factor for women than men, while "good" cholesterol, HDL, has a more protective effect on women. Researchers are now looking more closely at the long-term survival rates of men and women, up to two years after a heart attack.

Risk factors for heart disease

  • high blood pressure
  • high cholesterol
  • family history
  • smoking
  • obesity
  • diabetes

Differences in male and female biology are obviously important factors to consider in the detection and treatment of heart disease. We’re pleased that more attention is being focused on how women experience the disease.

Dr. Vaccarino is an assistant professor of epidemiology at the Yale University School of Medicine.

Learn more about risk factors for cardiac disease

The cardiac services section of the Yale-New Haven Hospital web site discusses risk factors you can control....and those you cannot. We also provide a link to the American Heart Association online risk assessment.

Are you at risk?


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