Women who are hospitalized for a heart attack are less likely to experience chest pain and are more likely to die than men the same age.

An analysis published in the Journal of the American Medical Association is the largest to examine the interplay among gender, age and chest pain when it comes to death from heart disease, the leading killer worldwide. Chest pain is the hallmark symptom of a heart attack, according to the researchers, who suggested that its absence might help explain women's increased risk.

The study examined the records of 1.1 million Americans from 1994 to 2006 in the National Registry of Myocardial Infarction, the world's largest database of heart attack patients. Forty-two percent of women reported no chest pain when they were hospitalized for a heart attack, compared with 30.7 percent of men. Almost 15 percent of the women died, compared with 10 percent of men.

"Our data suggest that the absence of chest pain is associated with increased mortality, especially among younger women," said the researchers, led by John Canto of the Watson Clinic and Lakeland Regional Medical Center in Florida. "Patients without chest pain and discomfort tend to present later, are treated less aggressively and have almost twice the short-term mortality compared with those presenting with more typical symptoms."

The greater risk of dying for women not having chest pain decreased with age; the oldest women were less likely to die than men of the same age who weren't suffering tell-tale heart attack signs.

Chest pain and discomfort were still the most common symptoms among those hospitalized for heart attacks, and they should be emphasized in public education, the researchers said. The finding that the absence of chest pain may help predict the risk of death is "provocative" and should be confirmed by additional studies, they said.

More than 1 million Americans suffer heart attacks each year, and half die as a result, according to the National Institutes of Health. The study didn't determine what other symptoms heart attack patients were having that put them in the hospital. Previous studies show that women having heart attacks may experience pain in the upper back or neck, indigestion, nausea, extreme fatigue and shortness of breath.

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