Prognostic Outcomes of Undiagnosed Myocardial Infarction in Men and Women
Overview
This large population-based study from the Rotterdam Study evaluated sex-specific long-term outcomes of unrecognized myocardial infarction (UMI) compared to recognized MI (RMI) and no MI. UMI was associated with increased risks of heart failure, stroke, atrial fibrillation, and all-cause mortality, with notable differences in risk magnitude and significance between women and men.
Background
Myocardial infarction (MI) is a leading cause of morbidity and mortality worldwide. Unrecognized MI (UMI), detected by ECG or imaging without clinical history, accounts for a substantial proportion of all MIs and is linked to adverse prognosis similar to recognized MI (RMI). Women have a higher proportion of UMIs among all MIs, potentially due to differences in symptom presentation and healthcare-seeking behavior. However, sex-specific differences in long-term outcomes after UMI remain incompletely understood.
Data Highlights
Outcome
Women HR (UMI vs No MI)
Women HR (RMI vs No MI)
Men HR (UMI vs No MI)
Men HR (RMI vs No MI)
Heart Failure
1.31 (1.01–1.71)
2.58 (1.94–3.43)
1.90 (1.45–2.48)
2.49 (2.09–2.98)
Atrial Fibrillation
0.96 (0.70–1.33)
1.62 (1.13–2.32)
1.91 (1.45–2.54)
1.79 (1.46–2.19)
Stroke
1.27 (0.95–1.70)
1.41 (0.98–2.04)
2.06 (1.52–2.80)
1.36 (1.06–1.76)
All-cause Mortality
1.21 (1.05–1.40)
1.81 (1.54–2.12)
1.59 (1.36–1.85)
1.63 (1.46–1.81)
Key Findings
Unrecognized MI (UMI) was associated with increased risk of heart failure and all-cause mortality in women, though these associations lost significance after adjusting for cardiovascular risk factors.
In men, UMI was significantly associated with higher risks of heart failure, atrial fibrillation, stroke, and all-cause mortality.
Recognized MI (RMI) conferred higher risks of heart failure, atrial fibrillation, and mortality in both sexes, with stronger associations in women for heart failure and mortality.
Stroke risk was significantly elevated in men with UMI but not in women.
Cardiovascular risk factors contributed differently to the associations between MI status and outcomes by sex, suggesting sex-specific pathophysiological mechanisms and risk profiles.
Clinical Implications
Clinicians should be aware that unrecognized myocardial infarction carries a substantial risk of adverse cardiovascular outcomes, particularly in men. Sex-specific risk assessment and management strategies may be warranted to improve detection and prevention of complications following UMI. Early identification and targeted interventions could mitigate progression to heart failure, atrial fibrillation, stroke, and premature mortality.
Conclusion
Unrecognized myocardial infarction is a clinically important entity with differential prognostic implications in women and men. These findings underscore the need for improved detection and sex-tailored approaches to cardiovascular risk stratification and secondary prevention.
References
Rotterdam Study Investigators/2024 -- Prognostic Outcomes of Undiagnosed Myocardial Infarction in Men and Women: Insights from the Rotterdam Study
Despite major advances in guideline-directed medical therapy (GDMT), worsening heart failure continues to drive significant morbidity, repeat hospitalizations and healthcare utilization worldwide.
