Striking Sex Differences in Acute MI Risk Factors in Younger Adults

Young adults who have an acute MI before age 55 have many risk factors in common no matter their sex, but a new analysis of data from the VIRGO study shows that psychosocial risk factors carry special weight among women.

Yuan Lu, ScD (Yale New Haven Hospital, CT), the study’s lead author, pointed out to TCTMD that while young women account for a just a sliver of the overall population with cardiovascular disease, this translates to 40,000 MI-related hospitalizations in the United States each year. Yet awareness about the risk is lacking among both patients and clinicians, she noted.

For women, acute MIs carry a high mortality burden after they occur, making the case for better primary prevention, Lu stressed. “Understanding the risk factors would be very important to inform the target of the intervention.”

The sex differences they found were striking, she said, and they point to the need for targeted prevention strategies. Mental health and income level, for instance, mattered more for women than they did for men. High cholesterol, on the other hand, was more instrumental for men, possibly because many of the female patients in the below-55 age bracket are premenopausal, she suggested.  

Their study, published online in JAMA Network Open, is one of the most comprehensive on this topic to date, said Lu.

Income, Mental Health, and More

VIRGO, a multicenter registry, was designed to study the effects of sex on outcome in young MI patients. Lu and colleagues performed a matched case-control study comparing 2,264 patients in VIRGO who had an acute MI before age 55 with 2,264 population-based controls from the National Health and Nutrition Examination Survey. Among them, 68.9% were women and the median age was 48 years.

The researchers identified seven risk factors that, taken together, accounted for around 85% of the total MI risk in men and women. However, there were differences in the strengths of the associations. Notably, low household income was significantly linked to acute MI in women but not in men.

Risk Factors for Acute MI in Young Adults

Diabetes, depression, hypertension, and current smoking contributed more toward the total risk of acute MI in women than in men, whereas hypercholesterolemia and family history of premature MI were larger contributors for men.

Additionally, traditional CV risk factors were both more prevalent and more strongly associated with type 1 MI as compared with type 2 MI.

How to apply this information in practice remains a difficult question, said Lu. “I think the first step [is] to raise awareness in clinicians and patients about heart attack in young women.” It’s important, she continued, to ask younger women about things like depression, stress, and income. “Once we identify those young women that could potentially be at high risk of developing heart disease, then we can connect them, say, to social workers or community health workers.” Patients with lower incomes might benefit from coupons to use at the pharmacy or discounts on parking and transportation, for instance.

Unlike lab values, “social factors are not commonly documented in electronic health records,” she observed, adding, “Because they are not documented, the next time you come to see the doctor, the doctor cannot view your social history, and they cannot weigh in and make clinical decisions to address that.” It can be hard to standardize these details in a way that fits on a typical “dashboard,” she acknowledged, and to fit the screening process into a 15-minute appointment.

In terms of research, Yu said that the next step is an analysis focused on female VIRGO study participants, exploring how things like their menopausal and reproductive history relate to MI risk in comparison to population-based controls. Another area ripe for further study is a risk prediction tool tailored to young patients.