Today, I review, link to, and excerpt from Medscape Medical News‘ More Than Half of Heart Attacks in Younger Women Have Nontraditional Causes.* Jo Shorthouse, September 15, 2025.
*More Than Half of Heart Attacks in Younger Women Have Nontraditional Causes – Medscape – September 15, 2025.
All that follows is from the above resource.
A community-based study in Olmsted County, Minnesota, has documented the distribution of myocardial infarction (MI) causes in patients younger than 65 years, showing significant sex differences.
Published in the Journal of the American College of Cardiology, the study analyzed 4116 troponin-positive events in 2780 patients between 2003 and 2018. Researchers found that 53% vs 25% of heart attacks in women vs men aged 65 years or younger were due to nonatherosclerotic causes.
Study Methodology and Findings
Investigators classified MIs into six categories: atherothrombosis, spontaneous coronary artery dissection (SCAD), embolism, vasospasm, myocardial infarction with nonobstructed coronary arteries of unknown cause (MINOCA-U), and supply-demand mismatch (SSDM).
A community-based study in Olmsted County, Minnesota, has documented the distribution of myocardial infarction (MI) causes in patients younger than 65 years, showing significant sex differences.
Published in the Journal of the American College of Cardiology, the study analyzed 4116 troponin-positive events in 2780 patients between 2003 and 2018. Researchers found that 53% vs 25% of heart attacks in women vs men aged 65 years or younger were due to nonatherosclerotic causes.
Study Methodology and Findings
Investigators classified MIs into six categories: atherothrombosis, spontaneous coronary artery dissection (SCAD), embolism, vasospasm, myocardial infarction with nonobstructed coronary arteries of unknown cause (MINOCA-U), and supply-demand mismatch (SSDM).
In women younger than 65 years, 47% of MIs were caused by atherothrombosis and 53% by other mechanisms. The breakdown included SSDM (34%), SCAD (11%), vasospasm (3%), embolism (2%), and MINOCA-U (3%). In contrast, atherothrombosis represented 75% of MIs in men younger than 65 years.
“The most important take-home message is the need for heightened recognition of nonatherosclerotic causes of acute coronary syndrome, particularly in younger patients and women,” said lead author Claire E. Raphael, MBBS, PhD, from Mayo Clinic’s Department of Cardiovascular Medicine, Rochester, Minnesota. “These patients often lack traditional cardiovascular risk factors, and as a result, their symptoms may not always trigger a full cardiac workup.”
Diagnostic Accuracy Over Time
The study reported that 55% of SCAD cases were initially misclassified, often as atherothrombotic disease or MINOCA. The incidence of SCAD was 5.2 vs 0.9 per 100,000 person-years in women vs men.
Most reclassifications occurred in cases presented before 2012, with 80% of the 61 revised cases occurring during this earlier period. Recognition improved after 2012, coinciding with research that defined angiographic characteristics and management strategies for SCAD.
“Recognition of SCAD improved dramatically after 2012,” Raphael noted, referencing pivotal publications that defined angiographic hallmarks and highlighted procedural considerations.
Mortality Patterns by Cause
Five-year mortality varied widely:
- SCAD: 0%
- Atherothrombosis: 8%
- Embolism: 8%
- SSDM: 33%
“Supply-demand mismatch is fundamentally a marker of severe systemic illness rather than a primary cardiac event, and its prognosis is largely driven by the underlying noncardiac disease burden,” explained co-author Rajiv Gulati, MD, PhD, also from Mayo Clinic.
Commenting on the paper, C. Noel Bairey Merz, MD, director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai, Los Angeles, observed changes in clinical practice. “I think it’s happening now,” she said, referring to recognition of conditions like SCAD. “I see fellows presenting SCAD cases, probably not as much as we would like, but I do think the interventional community, the younger trainees, are on it,” she told Medscape Medical News.
Clinical Observations and Techniques
Raphael and colleagues described specific angiographic approaches used in their diagnostic process. “During invasive angiography, meticulous technique is paramount,” Raphael explained. “This includes ensuring adequate contrast opacification, performing long cine runs, and carefully interrogating the distal vasculature, where subtle dissections or embolic lesions can otherwise be missed.”
In uncertain cases, the team used second-operator review and intravascular imaging with intravascular ultrasound or optical coherence tomography.
The study found that 34% of patients with nonatherothrombotic coronary MI underwent cardiovascular MRI, 19% received intracoronary imaging, and 1% had invasive provocation testing.
Population Demographics and Disease Distribution
Women had lower overall heart attack incidence than men (48 vs 137 per 100,000 person-years), particularly for atherothrombotic causes (23 vs 105 per 100,000 person-years). In women younger than 45 years, SSDM was the most common cause of heart attack, and acute nonatherothrombotic coronary causes collectively occurred as frequently as atherothrombosis.
Bairey Merz noted ongoing knowledge gaps, particularly regarding type 2 MIs. “We don’t know best practices,” she said. “The prognosis is not great, but it’s not horrible either.”
Study Context and Limitations
The research represents what the authors describe as the first community-based study determining incidence and outcomes of individual causes of heart attack in a younger population. The study design used troponin T elevation above the 99th percentile as the sole inclusion criterion to maximize event capture.
The cohort was predominantly White (78%), and the authors acknowledged that findings may not be generalizable to other populations. They noted this as a key research gap requiring future investigation across different racial, ethnic, and geographic populations.
“Most of the patients in our study were White Americans, so we do not know if the cause of heart attacks would be different in a different population,” the authors stated in their interview with Medscape Medical News.
