For decades, the dominant narrative around heart attacks has been simple: fatty deposits (plaque) build up inside arteries, narrowing blood flow until a clot blocks it entirely, triggering a cardiac event. But new research by the Mayo Clinic suggests that reality is far more complex, especially for women and younger adults.
Published in the Journal of the American College of Cardiology, the study highlights that while atherosclerosis remains the leading cause of heart attacks, it accounts for only 47% of cases in women under 65, compared with 75% in men. In other words, more than half of female heart attack patients in this age group had other, less recognised causes behind their cardiac emergency.
A 15-Year Look Into Heart Attack Causes
Researchers analysed 1,474 heart attack cases from the Rochester Epidemiology Project, covering a 15-year period. The findings reveal a stark gap in how men and women experience heart attacks, underscoring why misdiagnoses and inappropriate treatments are not uncommon.
The study found that so-called non-plaque causes — such as arterial tearing, blood clots, or external stressors — are far more prevalent than previously assumed. These “non-traditional” causes are not only clinically different but also carry distinct risks and treatment requirements.
The Hidden Culprits Behind Many Attacks
- Spontaneous Coronary Artery Dissection (SCAD):
- A tear forms in the layers of the coronary artery wall, disrupting blood flow.
- SCAD disproportionately affects women, often those in their 40s or 50s who otherwise appear healthy and lack conventional risk factors.
- It was found to be nearly six times more common in women than in men.
- Cardiac Embolism:
- This occurs when a blood clot forms elsewhere in the body and travels to the heart’s arteries, blocking blood flow.
- Systemic Stressors (Anaemia or Infection):
- Conditions that weaken the body or increase strain on the heart can precipitate an attack even without clogged arteries.
- Alarmingly, heart attacks triggered by these stressors had the highest five-year mortality rate at 33%, suggesting that these cases can be deadlier than those caused by plaque.
Notably, fewer than 3% of cases remained unexplained after thorough expert review, countering the notion that some heart attacks have “mystery” origins.
Why Misdiagnosis Matters
The implications of these findings are profound. In many hospitals, SCAD and other non-plaque causes are misclassified as plaque-related heart attacks. That misstep can lead to aggressive interventions such as angioplasty and stent insertion, which are effective for blocked arteries but may worsen outcomes in SCAD patients.
Dr. Claire Raphael, interventional cardiologist at the Mayo Clinic and lead author of the study, stressed that diagnostic accuracy is key: “When we know the precise cause of a heart attack, we can personalise treatment, reduce harm, and improve survival.”
What This Means for Women and Younger Patients
Heart disease remains the world’s leading cause of death, but the gender gap in diagnosis has long been a concern. Women often present with atypical symptoms — such as nausea, shortness of breath, jaw pain, or extreme fatigue — that are dismissed or misattributed. This study provides new evidence that women are not only more likely to have different symptoms but also different underlying causes altogether.
In Malaysia and across Asia, awareness of conditions like SCAD remains limited. Cardiologists note that better training, improved diagnostic imaging, and stronger research into sex-specific heart health are urgently needed to reduce the risks of delayed or inappropriate care.
Global Perspective on a Growing Concern
The Mayo Clinic’s research adds to a growing body of evidence that cardiovascular disease is not “one-size-fits-all.” In Europe and the United States, similar studies have shown that 10–15% of women under 55 who suffer heart attacks have SCAD as the root cause. The new data suggests the proportion may be even higher in broader populations.
The findings also raise questions about public health messaging. Traditional campaigns focus on cholesterol, blood pressure, and lifestyle risk factors — all critical — but may not fully capture the risks faced by women without obvious indicators.
Implications for Malaysia and Beyond
Malaysia has one of the highest rates of cardiovascular disease in Southeast Asia. With non-communicable diseases already a major concern, the new insights into non-plaque causes of heart attacks may encourage policymakers to review diagnostic protocols. For instance:
- Training emergency physicians to consider SCAD when women present with chest pain.
- Expanding access to imaging technologies that can distinguish arterial tears from plaque blockages.
- Tailoring preventive campaigns for women and younger adults, not just older men with classic risk profiles.
A Call for More Personalised Heart Care
The takeaway from the study is clear: heart attacks are not all the same. Understanding the underlying cause — whether clogged arteries, dissection, clot, or systemic stressor — is critical to saving lives.
As Dr. Raphael concluded, “Our findings should remind clinicians and patients alike that heart attacks in younger adults, and especially in women, deserve careful evaluation. Treating them as identical to plaque-driven heart attacks risks missing the true picture — and the right treatment.”
