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Younger women at higher risk of dying after heart attacks

Heart disease is the number one killer of women. Each year all cardiovascular diseases combined claim the lives of more than 500,000 women in the U.S. compared to all forms of cancer, which kill about 258,000 women.

Women develop heart disease at the same rate as men do, but they often show evidence of the disease 10 years later than their male counterparts. As women approach menopause, their risk of heart disease begins to approach that of men.

This year, nearly 50 million women in the U.S. are older than 50, and the percentage of postmenopausal women in our society is rising as the baby boomers become senior boomers. For the last decade, many medical researchers have focused on women and heart disease, examining gender differences in an effort to discover the most effective ways to treat increasing numbers of women heart disease patients.

Several of these studies have looked at how well women do after experiencing heart attacks compared with men. Most studies that have looked at long-term outcomes have generally found no differences in mortality rates between men and women, but these studies did not examine age in relation to gender and mortality. What we discovered in this study is that younger women’s increased risk of death at a younger age can be masked in a large sample of mostly older patients.

In 1999, Dr. Viola Vaccarino, several colleagues and I analyzed data of 155,565 women and 229,313 men who were enrolled in the National Registry of Myocardial Infarction (see October 1999 HealthLINK). We found overall about 11.5 percent of men and almost 16.7 percent of women died during hospitalization for heart attacks.

But when we divided patients by age, we found the younger the women, the higher their risk compared to men. Women younger than 50 had a mortality rate twice that of men their age, but this difference grew smaller with age; by age 75, the mortality rates were similar.

We found no explanation for this difference, but we wondered if the difference would persist after discharge. Women who break through the natural tendency to be protected from heart disease in the premenopausal years might have a very aggressive form of heart disease. We began to wonder how those who survive their heart attacks short-term do after two years. Would the difference in mortality rates still exist or would men catch up?

As the study summary shows, not only did the men not catch up, women continued to die at higher rates. We thought there might be a survivor effect—women who survived hospitalization might be stronger and do better than their male counterparts—but this wasn’t the case. We couldn’t attribute younger women’s poorer outcomes on different in-hospital treatment, their health history or any other parameter in the data.

The bottom line
What does this teach us? The bottom line is that we need to take heart disease in all women, including young women, very seriously. It is not a benign disease. When a woman has a heart attack, she and her physicians need to work together to do everything possible to ensure as good an outcome as possible, including participation in cardiac rehabilitation programs.

All women, but particularly those with a history of heart disease, need to know what a difference adopting healthy heart habits can make. Smoking cessation, reducing dietary fat and a regular exercise program have all been shown to reduce a woman’s risk of heart disease. (To read about a recent study that showed the dramatic difference healthy habits can make, go to December 1999, Women’s health HealthLINK)

In addition, women need to be aware of the symptoms of heart attack and seek treatment immediately if they notice any change in their health that could be a sign of trouble.

What are symptoms of heart attack in women?
When having a heart attack, some women experience the same severe chest pain or pressure that men often do. The sensation tends to be very intense and unrelieved by medication. However, many women have less "typical" symptoms. Rather than complaining of chest pain that could radiate to the arms or other areas of the upper body, they may only have feelings of bad indigestion that continue despite medication or burping. Other atypical symptoms include dizziness and shortness of breath.

We are early in our understanding of the differences between men and women, age and heart disease, and much research is needed. In the meantime, women need to take heart disease seriously and do what they can to protect themselves. Just as women have annual mammograms to detect early breast cancer, they should be discussing their heart disease risk factors with their physicians and seeking ways to reduce their risk.

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Dr. Krumholz is associate professor of cardiology at the Yale University School of Medicine and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation.