10 Points to Remember: AMI in Women
The following are key points to remember from an American Heart Association
Scientific Statement about acute myocardial infarction (AMI) in women:
1
Cardiovascular disease (CVD) is a
leading cause of mortality among
women. Since 1984, CVD mortality is
higher in women than men. However,
declines in CVD mortality among
women have been observed in the
past 2 decades, likely due to improved
receipt of evidence-based therapies,
and increased awareness of heart
disease among women. Yet gaps in
current management and understanding of AMI among women remain.
2
In the 12 months following AMI,
women are more likely to die than
men. Rates of heart failure (HF) and
stroke are also elevated for women.
This may in part be due to increased
rates of risk factors including diabetes, HF, hypertension, depression, and
renal dysfunction. Women are more
likely to experience non–ST-segment
elevation MI, spontaneous coronary
dissection, and coronary artery
spasm as compared to men.
3
Younger women remain at increased risk for death after AMI.
Given the recent increase in coronary
heart disease events among women
45-65 years of age, these trends
are concerning. Research related to
the age–gender relationship should
include sex-specific biology, clinical
manifestations, and an improved
understanding of the environmental
ACC.org/CSWN
and social factors that may increase
risk among younger women.
4
Race/ethnicity are also important
factors to be examined in relation to AMI in women. Black women
have a higher prevalence of AMI than
other women, including higher rates
of sudden cardiac death. Asian Indian
women also have higher mortality
rates, which may be associated with
higher rates of CVD risk factors.
5
AMI pathophysiology may also
differ among women compared to
men. Men have higher rates of plaque
rupture in the setting of AMI, while
for women, plaque rupture accounts
for approximately 55% of AMI. Plaque
erosion is more common in women
than man, in particular younger
women. Spontaneous coronary artery
dissection is a rare cause of AMI,
found more often among women
than men, particularly among young
women.
6
CVD risk factors are similar for
both men and women; however,
the potency of risk factors may differ.
Data from the INTERHEART study
suggest that 96% of population-attributable MI risk for women is related
to smoking, hypertension, diabetes,
central adiposity, diet, physical activity,
alcohol consumption, lipids, and psy-
chosocial factors, many of which are
modifiable. Smoking may have a stronger MI risk for women compared to
men. Hypertension is also a major risk
factor for women. Low high-density
lipoprotein (HDL) cholesterol, elevated
triglycerides, obesity, and diabetes—all
of which frequently occur together—
increase a woman’s risk for AMI.
7
Symptom presentation in the
setting of AMI differs for men
and women. Although most patients
present with typical chest pain, including women, women are more often
reporting atypical chest pain and/or
associated symptoms (dyspnea, fatigue,
weakness) compared to men. This may
account for greater treatment delays
observed in women compared to men.
8
Management of AMI also differs
among men and women. Thrombolytic therapy is recommended for
both men and women in the setting
of AMI for those who present to a
non-percutaneous coronary intervention (PCI)-capable hospital when
delay to performing PCI is estimated
to be >120 minutes. However, women
have a greater bleeding risk compared to men. Use of primary PCI for
women experiencing AMI lowers risk
of bleeds such as intracranial hemorrhage, yet other types of bleeds are
still higher among women than men.
9
Recommendations for medical
therapy after AMI are similar for
women and men, including beta-blockers,
angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers,
antiplatelet agents, and statins. Careful
monitoring of weight and renal function
may lower a woman’s bleeding risk related to antiplatelet therapy. Nonselective
beta-blockers should be used when coronary vasospasm is suspected. ACE inhibitors and statins are to be avoided during
pregnancy. Yet there is ample evidence to
suggest that receipt of such medications is
lower among women than men.
10
Recommendations to improve
management of AMI in women
include the correction of under-representation of women in clinical trials.
Data presented with sex- and genderspecific results are currently lacking
in many studies. Research gaps exist
related to coronary pathophysiology,
optimal diagnostic testing (including
imaging), optimal pharmacologic
and interventional strategies, and
the understanding of race/ethnicity,
socioeconomic, and psychological
factors. Thus, women’s cardiovascular
health requires a multidisciplinary
approach to both research and clinical
activities. ■
Mehta LS, Beckie TM, DeVon HA, et
al. Circulation. 2016;doi:10.1161/
CIR.0000000000000351.
CardioSource WorldNews
31