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. 2012 Feb 22;307(8):813-22.
doi: 10.1001/jama.2012.199.

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

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

John G Canto et al. JAMA. .
Free PMC article


Context: Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality.

Objective: To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI.

Design, setting, and patients: Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men).

Main outcome measures: We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality.

Results: The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .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 (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 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 < .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 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P < .001).

Conclusion: In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kiefe reports receiving partial funding from the National Institutes of Health (grants U01HL 105268 and U54 RR 026088). Mr Frederick reports being an employee of ICON Clinical Research, which received support from Genentech, to provide biostatistical and analytic services. Dr Peterson reported receiving research grants from Bristol-Myers Squibb, sanofi-aventis, Eli Lilly, Schering Plough/Merck, Johnson & Johnson, and St Jude Inc and consultant fees from Bayer and Pfizer. Dr Wenger reported receiving research grants and/or trial committee or data and safety monitoring board compensation from Pfizer, Merck, NHLBT, Gilead Sciences, Abbott, and Eli Lilly; she also reported receiving consultant fees from Gilead Sciences, AstraZeneca, Abbott Women's Advisory Board, Merck, and Pfizer.


Figure. Sex Differences in Myocardial Infarction Presentation Without Chest Pain/Discomfort, Stratified by Age
P< .001 for all comparisons. In these multivariable models, candidate variables for inclusion in the model include demographics, baseline characteristics, cardiovascular risk factors, and medical history (Table 1). Separate adjusted models were performed within each age stratum to find the age-stratum-specific odds ratio (OR) for women vs men, and within each age stratum, the reference group was men.

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