Atypical presentation of acute coronary syndrome: A significant independent predictor of in-hospital mortality

Symptomology, Outcomes and Risk Factors of Acute Coronary Syndrome Presentations without Cardiac Chest Pain: A Scoping Review

For patients experiencing acute coronary syndrome, early symptom recognition is paramount; this is challenging without chest pain presentation. The aims of this scoping review were to collate definitions, proportions, symptoms, risk factors and outcomes for presentations without cardiac chest pain. Full-text peer reviewed articles covering acute coronary syndrome symptoms without cardiac chest pain were included. MEDLINE, CINAHL, Scopus and Embase were systematically searched from 2000 to April 2023 with adult and English limiters; 41 articles were selected from 2,954. Dyspnoea was the most reported (n=39) and most prevalent symptom (11.6-72%). Neurological symptoms, fatigue/weakness, nausea/ vomiting, atypical chest pain and diaphoresis were also common. Advancing age appeared independently associated with presentations without cardiac chest pain; however, findings were mixed regarding other risk factors (sex and diabetes). Patients without cardiac chest pain had worse outcomes: increased mortality, morbidity, greater prehospital and intervention delays and suboptimal use of guideline driven care. There is a need for structured data collection, analysis and interpretation.

The Effect of Beta-Blocker Post-Myocardial Infarction With Ejection Fraction >40% Pooled Analysis From Seven Arabian Gulf Acute Coronary Syndrome Registries

The use of beta-blockers (BB) in reduced left ventricular ejection fraction (LVEF) post-myocardial infarction (MI) is associated with reduced 1-year mortality, while their role in patients with mid-range and preserved LVEF post-MI remains controversial. We studied 31,620 patients who presented with acute coronary syndrome (ACS) enrolled in seven Arabian Gulf registries between 2005 and 2017. Patients with LVEF ≤40% were excluded. The remaining cohort was divided into two groups: BB group (n = 15,541) and non-BB group (n = 2,798), based on discharge medications. Patients in the non-BB group were relatively younger (55.3 vs. 57.4, P = .004) but higher risk at presentation; with higher Global Registry of Acute Coronary Events (GRACE) score (119.2 vs 109.2, P < .001), higher percentage of cardiogenic shock (3.5 vs 1.4%, P < .001), despite lower prevalence of comorbidities, such as hypertension and hyperlipidemia. BB use was associated with lower 1-year mortality in a multivariate logistic regression analysis, adjusting for major confounders [adjusted odds ratio (OR): 0.71 (95% CI 0.51-0.99)]. This remained the case in a sensitivity analysis using propensity score matching [adjusted OR: 0.34 (95% CI 0.16-0.73)]. In this study, using Arabian Gulf countries registries, the use of BB after ACS with LVEF >40% was independently associated with lower 1-year mortality.

Time to presentation and mortality outcomes among patients with diabetes and acute myocardial infarction

BACKGROUND/AIMS

Due to limited real-world evidence on the association between time to presentation (T2P) and outcomes following acute myocardial infarction and diabetes (AMI-DM), we investigated the characteristics of patients with AMI-DM and their outcomes based on their T2P.

METHODS

4,455 patients with AMI-DM from a Korean nationwide observational cohort (2011-2015) were divided into early and late presenters according to symptom-to-door time. The effects of T2P on three-year all-cause mortality were estimated using inverse probability of treatment weighting (IPTW) and survival analysis.

RESULTS

The incidence of all-cause mortality was consistently higher in late presenters than in early presenters (11.4 vs. 17.2%; p < 0.001). In the IPTW-adjusted dataset, the incidence of all-cause mortality was numerically higher in late presenters than in early presenters (9.1 vs. 12.4%; p = 0.072). In the survival analysis, the cumulative incidence of all-cause mortality was significantly higher in late presenters than in early presenters before and after IPTW. In the subgroup with ST-elevation myocardial infarction, late presenters had a higher incidence of cardiac death than early presenters before (4.8 vs. 10.5%; p < 0.001) and after IPTW (4.2 vs. 9.7%; p = 0.034). In the initial glycated hemoglobin (HbA1c)-stratified analysis, these effects were attenuated in patients with HbA1c ≥ 9.0% before (adjusted hazard ratio [HR]: 1.45, 95% confidence interval [CI]: 0.80-2.64) and after IPTW (adjusted HR: 0.82, 95% CI: 0.40-1.67).

CONCLUSION

Late presentation was associated with higher mortality in patients with AMI-DM; therefore, multifaceted and systematic interventions are needed to decrease pre-hospital delays.

The Influence of Sex, Age, and Race on Coronary Artery Disease: A Narrative Review

Cardiovascular disease has remained one of the leading causes of mortality in the world. The basic pathophysiology of coronary artery disease (CAD) is a reduction of the blood flow in coronary vessels, leading to restricted blood flow to the heart muscle. Both modifiable and non-modifiable risk factors contribute to its multifactorial etiology. The clinical presentation ranges from asymptomatic to typical symptoms like chest pain, shortness of breath, and left arm or jaw pain. The purpose of this review is to investigate and analyze the variation of CAD depending on the biological sex, age, race, or ethnicity and how it might differ in the studied population while comparing the symptoms and prognosis of CAD. For this research, PubMed's database was used. A total of 926 articles were selected using pre-determined inclusion and exclusion criteria, with 74 articles eligible to be included in the narrative review. Studies were selected from the general population of patients with CAD, regardless of their severity, stage of diagnosis, and treatment plan. The scale for the assessment of non-systematic review articles (SANRA) was used to assess the quality of the study. As humans age, the incidence of CAD increases, and people over 75 are more likely to have multiple-vessel CAD. It has been observed that South Asians have the highest rate of CAD at 24%, while the White population has the lowest at 8%. The prevalence of CAD also depends on race, with the White population having the lowest rate at 3.2%, followed by Hispanics at 5%, Black women at 5.2%, and Black men at 5.7%. Younger Black women tend to have more chest pain. Men with CAD commonly experience chest pain, and women are more likely to present with atypical symptoms. Modifiable risk factors such as smoking and alcoholism are more commonly observed in young men than in young women. Coronary artery disease in the elderly, female, minority, and Black patients is associated with a higher mortality rate. Acknowledging the prevalence of certain risk factors, signs, results, and responses to treatment in certain socio-demographic groups, as well as the provision and accessibility of diagnosis and treatment, would lead to a better outcome for all individuals. The impact of this shift can range from an earlier diagnosis of CAD to a faster and more customized treatment plan tailored to each patient's individual requirements.

A Comparative Study of Ischemia-Modified Albumin: A Promising Biomarker for Early Detection of Acute Coronary Syndrome (ACS)

Introduction The second most common cause of emergency department (ED) visits is chest pain and discomfort. Timely identification or threat stratification is crucial for identifying high-risk individuals who benefit from sophisticated diagnostic investigations (including cardiac biomarkers) and early relevant therapies. We aimed to assess the levels of ischemia-modified albumin (IMA) and also to study its sensitivity and specificity in comparison with cardiac troponin T/troponin I and electrocardiogram (ECG) (alone and in combination) in the diagnosis of acute myocardial infarction. Methods Adults (either gender) presented at the ED of a tertiary care centre with classical chest pain suggestive of angina pectoris or angina-like chest pain and ECG changes suggestive of ACS, ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial MI (NSTEMI), and unstable angina, within three hours of onset were enrolled. Demographic and clinical information was recorded. ECG, haematological investigations like complete blood count, blood sugar level, lipid profile, IMA, troponin I, and creatinine kinase-MB (CK-MB), and radiological investigations like 2D-echocardiography (2D-ECHO) and coronary angiography were performed. Results A total of 100 subjects were enrolled in the study out of which 50 were cases and 50 were controls. Cases were older as compared to controls (mean age 60.5 versus 46.0 years). Of the 50 cases, 33 (66%) were males. There were equal numbers of males (33 each) and females (17 each) subjects in both the groups. Typical chest pain, risk factors, and history of coronary artery disease (CAD) were higher in cases. ECG diagnosis revealed the presence of STEMI (52%) and coronary angiography revealed the presence of double vessel CAD (60%) in cases. Among controls, gastroesophageal reflux disorder was the most common cause of chest pain followed by costochondritis and pneumonia. Glucose (fasting and postprandial), all lipid profile parameters (except high-density lipoprotein) and IMA values were significantly higher in cases as compared to controls. A combination of ECG+IMA has the highest sensitivity (90%) with 79% PPV in the diagnosis of ACS within three hours of the onset of chest pain, and ECG+IMA+2D-ECHO had similar results. However, ECG is equally sensitive. IMA alone has 64% sensitivity with 82% diagnostic accuracy which was higher than other biomarkers (CK-MB, cardiac troponin I). Conclusions As found in our study, among the biomarkers used, the diagnostic accuracy of IMA was the highest and better than that of cardiac troponin I and CK-MB. Although ECG is the preferred diagnostic tool for diagnosing ACS (STEMI, NSTEMI, and unstable angina) in patients presenting within three hours of the onset of chest pain, a confirmation can be done with the help of other diagnostic tests and investigations like serum IMA levels and further treatment can be initiated.

[Characteristics of chest pain in acute coronary syndromes seen in the cardiology department of Befelatanana (Madagascar)]

INTRODUCTION

Chest pain is one of the different elements of orientation for the diagnosis of acute coronary syndrome. Sometimes its clinical presentation is misleading. The objective of this study was to describe the characteristics of chest pain during an acute coronary syndrome in the cardiology department of the Joseph Raseta Befelatanana University Hospital Center, Antananarivo, Madagascar.

METHODS

We carried out a cross-sectional, descriptive study of 10 months from January 2019 to October 2019. All patients diagnosed with acute coronary syndrome during this period were included.

RESULTS

Sixty-five cases were included. A "typical chest pain" was only encountered in 7.7% of cases. Advanced age (p = 0.04) and sedentary lifestyle (p = 0.03) were associated with the occurrence of silent myocardial ischemia, and. hypertension with a prolonged duration (≥15 minutes) of chest pain (p = 0.03). Dyslipidemia was associated with atypical irradiation of chest pain (p = 0.003). Alcoholism had an impact on pain triggered by effort (p = 0.01) and relieved by rest (p = 0.04).

CONCLUSION

The current symptomatology of acute coronary syndrome is increasingly atypical. Knowledge of the factors that can influence the different characteristics of chest pain could serve as a benchmark in clinical practice in our population.

Sex Differences in Acute Coronary Syndromes: A Global Perspective

Despite increasing evidence and improvements in the care of acute coronary syndromes (ACS), sex disparities in presentation, comorbidities, access to care and invasive therapies remain, even in the most developed countries. Much of the currently available data are derived from more developed regions of the world, particularly Europe and the Americas. In contrast, in more resource-constrained settings, especially in Sub-Saharan Africa and some parts of Asia, more data are needed to identify the prevalence of sex disparities in ACS, as well as factors responsible for these disparities, particularly cultural, socioeconomic, educational and psychosocial. This review summarizes the available evidence of sex differences in ACS, including risk factors, pathophysiology and biases in care from a global perspective, with a focus on each of the six different World Health Organization (WHO) regions of the world. Regional trends and disparities, gaps in evidence and solutions to mitigate these disparities are also discussed.

A qualitative study of COVID-19 related reasons for delayed presentation of patients with chest pain during the COVID-19 pandemic

Introduction

In previous pandemics such as the Ebola virus outbreak in West Africa, it has been observed that patients with non-pandemic related complaints, delay their presentation to hospital. Similarly, delayed presentation of patients with chest pain during the COVID-19 pandemic has been documented. This qualitative study identified the COVID-19 related reasons which lead to this delay.

Methods

A qualitative study based on 10 individual patient interviews. Half of these were conducted at a public hospital emergency centre (EC) and the other half at a private EC.

Results

A variety of psychosocial factors were identified as themes for delayed presentation. Interestingly, the fear of contracting COVID-19 at the hospital was not found to be an important theme in our study. Rather, confusion around hospital protocols during the pandemic was identified as a recurrent theme.

Discussion

This study found that confusion about COVID-19 hospital protocols was the major pandemic related delaying factor. A number of themes unrelated to COVID-19 were also identified.

Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study

OBJECTIVE

The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED).

METHODS

Observational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints.

RESULTS

Of 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25-1.45)) and adjusted (AOR 1.34(1.24-1.46)) risks for mortality, and unadjusted (OR 1.54(1.46-1.63)) and adjusted (AOR 1.46(1.37-1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache.

CONCLUSIONS

Although patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.

Clinical Profile of Acute Coronary Syndrome Presentation to the Ladysmith Provincial Hospital: High Prevalence Among the Minority Indian Population

Background

Cardiovascular diseases were responsible for 17% of the 460236 natural deaths in South Africa in 2015. Previous studies have reported a disproportionately higher incidence of ischemic heart disease (IHD) and its risk factors among individuals of Indian descent residing in South Africa. The aim of this study was to explore the clinical profile of patients presenting with a diagnosis of acute coronary syndrome (ACS) and to compare the characteristics of patients of Indian descent to those of non-Indian descent.

Methods

Retrospective data were derived from the medical charts of 160 consecutive patients presenting to the Ladysmith Provincial Hospital over a 44-month period with a diagnosis of ACS. Findings were described and compared.

Results

The mean (SD) age of study patients was 55.8 (±12.8) years. The majority of subjects were male (n=90, 56.3%) and unemployed (n=98, 62.3%). The racial distribution of the study sample comprised 103 (64.4%) Indian, 36 (22.5%) Black, and 21 (13.1%) White subjects. Compared to non-Indian subjects, a significantly higher proportion (p<0.05) of Indian subjects were male (64.7% vs 41.4%), cigarette smokers (52.0% vs 32.8%), had a previous history of ACS (37.3% vs 10.3%), were diabetic (33.3% vs 17.2%), and were hypertensive (58.8% vs 29.3%).

Conclusion

The disproportionately high frequency of ACS among the minority Indian population of Ladysmith is concerning. There is a need for rigorous public health interventions to create local awareness, encourage lifestyle modification, and thereby improve control of cardiovascular risk factors, especially among high-risk population groups.

Understanding timely STEMI treatment performance: A 3-year retrospective cohort study using diagnosis-to-balloon-time and care subintervals

OBJECTIVE

From the perspective of percutaneous coronary intervention (PCI) centers, locations of ST-segment elevation myocardial infarction (STEMI) diagnosis can include a referring facility, emergency medical services (EMS) transporting to a PCI center, or the PCI center's emergency department (ED). This challenges the use of door-to-balloon-time as the primary evaluative measure of STEMI treatment pathways. Our objective was to identify opportunities to improve care by quantifying differences in the timeliness of STEMI treatment mobilization based on the location of the diagnostic ECG.

METHODS

This 3-year, single-center, retrospective cohort study classified patients by diagnostic ECG location: referring facility, EMS, or PCI center ED. We quantified door-to-balloon-time and diagnosis-to-balloon-time with its care subintervals.

RESULTS

Of 207 ED STEMI patients, 180 (87%) received PCI. Median diagnosis-to-balloon-times were shortest among the ED-diagnosed (78 minutes [interquartile range (IQR), 61-92]), followed by EMS-identified patients (89 minutes [IQR, 78-122]), and longest among those referred (140 minutes [IQR, 119-160]), reflecting time for transport to the PCI center. Conversely, referred patients had the shortest median door-to-balloon-times (38 minutes [IQR, 34-43]), followed by the EMS-identified (64 minutes [IQR, 47-77]), whereas ED-diagnosed patients had the longest (89 minutes [IQR, 70-114]), reflecting diagnosis and catheterization lab activation frequently occurring before PCI center ED arrival for referred and EMS-identified patients.

CONCLUSIONS

Diagnosis-to-balloon-time and its care subintervals are complementary to the traditional door-to-balloon-times as measures of the STEMI treatment process. Together, they highlight opportunities to improve timely identification among ED-diagnosed patients, use of out-of-hospital cath lab activation for EMS-identified patients, and encourage pathways for referred patients to bypass PCI center EDs.

The receptive field for visceral pain referred orofacially by the vagus nerves

BACKGROUND

The nociceptive receptive field of the vagus nerves in animals includes virtually the entire thoracic, abdominal and laryngopharyngeal regions. However, the role of the vagus nerves in the transmission of visceral pain in humans, with the exception of pain from coronary artery diseases, is believed to be insignificant.

AIM

The purpose of this report is to map out the clinical visceral pain receptive field of the vagus nerves relative to its nociceptive counterpart in animals.

MATERIALS AND METHODS

The PubMed database and PMC were searched for case reports of patients with orofacial pain believed by the author(s) of the article to be referred from underlying non-cardiac thoracic, laryngopharyngeal or abdominal diseases. Reports of diseases for which non-neural explanations for the orofacial spread of pain were suggested were excluded.

RESULTS

A total of 52 case reports of jaw pain and/or otalgia referred from laryngopharyngeal and noncardiac thoracic sources were discovered. In addition, a multicenter prospective study found that 25.8% of more than 3,000 patients with thoracic aortic dissection experienced pain in the head and neck region. In stark contrast, no case reports of orofacially referred pain from abdominal diseases were found.

DISCUSSION

The results indicate that the laryngopharyngeal and thoracic portions of the vagal receptive field are capable of referring pain orofacially while the abdominal portion is not. The roles of the somatotopic organization of the trigeminal sub nucleus caudalis and neuromodulation in this referral of pain were discussed.

CONCLUSION

Referred orofacial pain can lead to delayed diagnosis and poorer outcome in visceral diseases.

Angiographic characteristics and in-hospital mortality among patients with ST-segment elevation myocardial infarction presenting without typical chest pain: an analysis of China Acute Myocardial Infarction registry

Background:

Patients with ST-segment elevation myocardial infarction (STEMI) who present without typical chest pain are associated with a poor outcome. However, whether angiographic characteristics are related to a higher risk of mortality in this population is unclear. This study aimed to investigate whether the higher mortality risk in patients with STEMI without chest pain could be explained by their “high-risk” angiographic characteristics.

Methods:

We used data of 12,145 patients with STEMI who was registered in China Acute Myocardial Infarction registry from January 2013 to September 2014. We compared the infarct-related artery (IRA), thrombolysis in myocardial infarction (TIMI) flow grade in the IRA, and other angiographic characteristics between patients without and those with chest pain. Multivariable logistic regression model was used to identify independent risk factor of in-hospital mortality.

Results:

The 2922 (24.1%) patients with STEMI presented without typical chest pain. These patients had a higher TIMI flow grade (mean TIMI flow grade: 1.00 vs. 0.94, P = 0.02) and a lower rate of IRA disease of the left anterior descending artery (44.6% vs. 51.2%, χ² = 35.63, P < 0.01) than did those with typical chest pain. Patients without chest pain were older, more likely to have diabetes, longer time to hospital and higher Killip classification, and less likely to receive optimal medication treatment and primary percutaneous coronary intervention and higher In-hospital mortality (3.3% vs. 2.2%, χ² = 10.57, P < 0.01). After adjusting for multi-variables, presentation without chest pain was still an independent predictor of in-hospital death among patients with STEMI (adjusted odds ratio: 1.36, 95% confidence interval: 1.02–1.83).

Conclusions:

Presentation without chest pain is common and associated with a higher in-hospital mortality risk in patients with acute myocardial infarction. Our results indicate that their poor prognosis is associated with baseline patient characteristics and delayed treatment, but not angiographic lesion characteristics.

Clinical trial registration:

NCT01874691, https://clinicaltrials.gov.

Age-Related Sex Differences in Clinical Presentation, Management, and Outcomes in ST-Segment-Elevation Myocardial Infarction: Pooled Analysis of 15 532 Patients From 7 Arabian Gulf Registries

Background No studies from the Arabian Gulf region have taken age into account when examining sex differences in ST-segment-elevation myocardial infarction (STEMI) presentation and outcomes. We examined the relationship between sex differences and presenting characteristics, revascularization procedures, and in-hospital mortality after accounting for age in patients hospitalized with STEMI in the Arabian Gulf region from 2005 to 2017. Methods and Results This study was a pooled analysis of 31 620 patients with a diagnosis of acute coronary syndrome enrolled in 7 Arabian Gulf registries. Of these, 15 532 patients aged ≥18 years were hospitalized with a primary diagnosis of STEMI. A multiple variable regression model was used to assess sex differences in revascularization, in-hospital mortality, and 1-year mortality. Odds ratios and 95% CIs were calculated. Women were, on average, 8.5 years older than men (mean age: 61.7 versus 53.2 years; absolute standard mean difference: 68.9%). The age-stratified analysis showed that younger women (aged <65 years) with STEMI were more likely to seek acute medical care and were less likely to receive thrombolytic therapies or primary percutaneous coronary intervention and guideline-recommended pharmacotherapy than men. Women had higher crude in-hospital mortality than men, driven mainly by younger age (46-55 years, odds ratio: 2.60 [95% CI, 1.80-3.7]; P<0.001; 56-65 years, odds ratio: 2.32 [95% CI, 1.75-3.08]; P<0.001; and 66-75 years, odds ratio: 1.79 [95% CI, 1.33-2.41]; P<0.001). Younger women had higher adjusted in-hospital and 1-year mortality rates than younger men (P<0.001). Conclusions Younger women (aged ≤65 years) with STEMI were less likely to receive guideline-recommended pharmacotherapy and revascularization than younger men during hospitalization and had higher in-hospital and 1-year mortality rates.

Clinical Impact of Atypical Chest Pain and Diabetes Mellitus in Patients with Acute Myocardial Infarction from Prospective KAMIR-NIH Registry

Atypical chest pain and diabetic autonomic neuropathy attract less clinical attention, leading to underdiagnosis and delayed treatment. To evaluate the long-term clinical impact of atypical chest pain and diabetes mellitus (DM), we categorized 11,159 patients with acute myocardial infarction (AMI) from the Korea AMI-National Institutes of Health between November 2011 and December 2015 into four groups (atypical DM, atypical non-DM, typical DM, and typical non-DM). The primary endpoint was defined as patient-oriented composite endpoint (POCE) at 2 years including all-cause death, any myocardial infarction (MI), and any revascularization. Patients with atypical chest pain showed higher 2-year mortality than those with typical chest pain in both DM (29.5% vs. 11.4%, p < 0.0001) and non-DM (20.4% vs. 6.3%, p < 0.0001) groups. The atypical DM group had the highest risks of POCE (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.48-2.10), all-cause death (HR 2.23, 95% CI 1.80-2.76) and any MI (HR 2.34, 95% CI 1.51-3.64) in the adjusted model. In conclusion, atypical chest pain was significantly associated with mortality in patients with AMI. Among four groups, the atypical DM group showed the worst clinical outcomes at 2 years. Application of rapid rule in/out AMI protocols would be beneficial to improve clinical outcomes.

Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study

OBJECTIVES

Successful treatment of acute coronary syndrome (ACS) relies on its rapid recognition. It is unclear whether the accepted presentation of chest pain applies to different ethnic groups. We thus examined potential ethnic variations in ACS symptoms and clinical care outcomes in white, South Asian and Chinese patients.

DESIGN

Cross-sectional survey.

SETTING

Participants were hospitalised at 1 of 12 Canadian centres across four provinces.

PARTICIPANTS

1334 patients with ACS (630 white; 488 South Asian; 216 Chinese).

MAIN OUTCOME MEASURES

ACS presentation symptoms (classic/typical midsternal pain/discomfort with or without radiation to the left neck, shoulder or arm) were assessed by self-report. Clinical care outcomes (time to emergency room [ER] presentation, cardiac catheterisation; receipt of cardiac catheterisation, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) were obtained by health record audit.

RESULTS

The mean age of the sample was 62 years and 30% had ST-elevation myocardial infarction (STEMI). The most common presenting symptom was midsternal pain/discomfort of any intensity regardless of ethnic status. Yet, a substantial proportion of patients reported atypical symptoms (33% white, 19% South Asian, 20% Chinese; p<0.006). After adjustment for age, sex, education, current smoking, extent of coronary artery disease, presence of diabetes or chronic kidney disease and STEMI vs non-STEMI/unstable angina, South Asians were more likely to present with at least moderate intensity midsternal pain/discomfort (adjusted OR [AOR] 1.44; 95% CI 1.05 to 1.98), whereas Chinese were less likely to present with radiating symptoms (AOR 0.53; 95% CI 0.38 to 0.74) compared with whites. South Asians with atypical pain (relative to those with midsternal pain/discomfort) took significantly longer to present to the ER (p=0.037), and were less likely to receive PCI (p=0.008) or CABG (p=0.041).

CONCLUSIONS

Atypical presentations were associated with greater delays in arrival to the emergency department and reduced invasive cardiovascular care in South Asians.

Differences in symptoms and pre-hospital delay among acute myocardial infarction patients according to ST-segment elevation on electrocardiogram: an analysis of China Acute Myocardial Infarction (CAMI) registry

BACKGROUND

Approximately 70% patients with acute myocardial infarction (AMI) presented without ST-segment elevation on electrocardiogram. Patients with non-ST segment elevation myocardial infarction (NSTEMI) often presented with atypical symptoms, which may be related to pre-hospital delay and increased risk of mortality. However, up to date few studies reported detailed symptomatology of NSTEMI, particularly among Asian patients. The objective of this study was to describe and compare symptoms and presenting characteristics of NSTEMI vs. STEMI patients.

METHODS

We enrolled 21,994 patients diagnosed with AMI from China Acute Myocardial Infarction (CAMI) Registry between January 2013 and September 2014. Patients were divided into 2 groups according to ST-segment elevation: ST-segment elevation (STEMI) group and NSTEMI group. We extracted data on patients' characteristics and detailed symptomatology and compared these variables between two groups.

RESULTS

Compared with patients with STEMI (N = 16,315), those with NSTEMI (N = 5679) were older, more often females and more often have comorbidities. Patients with NSTEMI were less likely to present with persistent chest pain (54.3% vs. 71.4%), diaphoresis (48.6% vs. 70.0%), radiation pain (26.4% vs. 33.8%), and more likely to have chest distress (42.4% vs. 38.3%) than STEMI patients (all P < 0.0001). Patients with NSTEMI were also had longer time to hospital. In multivariable analysis, NSTEMI was independent predictor of presentation without chest pain (odds ratio: 1.974, 95% confidence interval: 1.849-2.107).

CONCLUSIONS

Patients with NSTEMI were more likely to present with chest distress and pre-hospital patient delay compared with patients with STEMI. It is necessary for both clinicians and patients to learn more about atypical symptoms of NSTEMI in order to rapidly recognize myocardial infarction.

TRIAL REGISTRATION

www.clinicaltrials.gov (No. NCT01874691).

Atypical presentation of acute coronary syndrome (ACS): a case report

CASE

A 45-year-old man presented at the emergency department (ED) with stomach pain since eight days. The patient was not worried about his symptoms and requested only pain relief. The emergency physician requested a consult of the gastroenterologist. Clinical examination was unremarkable. However, 12-lead ECG and ischemic markers were suggestive of acute coronary syndrome (ACS) which led to admission at the cardiology department. Despite delayed presentation, the patient was still referred for urgent coronary angiogram after receiving heparin, ticagrelor and acetylsalicylic acid because of persistent pain. An acute occlusion of the posterior descending artery was visualized and a percutaneous coronary intervention (PCI) with implantation of a drug-eluting stent was performed.

DISCUSSION

Atypical presentation of ACS can range from non-chest pain to an epileptic seizure. Risk factors for atypical presentation include female gender, old age, comorbidities and severe mental illness. Troponin testing plays a central role when confronted with ACS but has only limited added-value with non-chest pain ACS. In cohort studies 1-2.2% of diagnosis of ACS is missed by emergency physicians. Possible explanations include atypical symptoms, non-diagnostic ECG and failure to interpret subtle ECG changes. ACS without chest pain frequently gets underdiagnosed and undertreated, which leads to more complications and a higher in-hospital mortality rate.

Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

A cluster and inferential analysis of myocardial infarction symptom presentation by age

BACKGROUND

Pre-hospital delay time in myocardial infarction is usually longer in older than in younger patients, with symptom presentation known to be a contributing factor.

AIM

The aim of this article is to examine symptom presentation differences, by age, in patients with myocardial infarction.

METHODS

This is a cross-sectional study using secondary analysis of a multi-site randomised controlled trial on pre-hospital delay time. Data were analysed using logistic regression and factor analysis.

RESULTS

Post-myocardial infarction patients were recruited prior to discharge ( n=1211), 54% were ≥65 years and 80% male. The average number of symptoms was three, with the ≥65 years age group reporting significantly less symptoms. Logistic regression controlling for gender, diabetes and diagnosis with 11 symptoms (χ²=52.09, p<0.001) was significant. Those ≥65 years had less chest symptoms, sweating, stomach upset and left arm pain, in addition to longer pre-hospital delay time. This group also had less symptom clustering and fewer symptoms within atypical clusters. Non-chest clusters occurred in 22% and 18% of the older and younger group respectively. Of note, two clusters 'atypical' (upset stomach/sweating) and 'typical arm' (right and left arm pain symptoms), accounted for 14% and 5% of myocardial infarction presentations in the ≥65 years group, within which 25% and 24% had no chest symptoms.

CONCLUSIONS

The results of this study indicate that myocardial infarction symptom presentation in older patients is likely to be less recognisable and more complex. Increased awareness of the presentation profile of older patients could expedite their triage, diagnosis and, consequently, their prognosis.

Clinical outcomes according to symptom presentation in patients with acute myocardial infarction: Results from the FAST-MI 2010 registry

BACKGROUND

Atypical clinical presentation in acute myocardial infarction (AMI) patients is not uncommon; most studies suggest that it is associated with unfavorable prognosis.

HYPOTHESIS

Long-term clinical impact differs according to predominant symptom presentation (typical chest pain, atypical chest pain, syncope, cardiac arrest, or dyspnea) in AMI patients.

METHODS

FAST-MI 2010, a nationwide French registry, included 4169 patients with AMI in 213 centers at the end of 2010 (76% of active centers). Demographics, medical history, hospital management, and outcomes were compared according to predominant symptom presentation.

RESULTS

Typical chest pain with no other symptom was reported in 3020 patients (68% in STEMI patients, 76% in NSTEMI patients). Atypical chest pain, dyspnea, syncope, and cardiac arrest were reported in 11%, 11%, 5%, and 1%, respectively. Patients with atypical clinical presentation had a higher cardiovascular risk profile and received fewer medications and a less invasive strategy. Using Cox multivariate analysis, atypical chest pain was not associated with higher death rate at 3 years (HR: 0.96, 95% CI: 0.69-1.33, P = 0.78), whereas cardiac arrest (HR: 2.44, 95% CI: 1.00-5.97, P = 0.05), syncope (HR: 1.70, 95% CI: 1.18-2.46, P = 0.005), and dyspnea (HR: 1.66, 95% CI: 1.31-2.10, P < 0.001) were associated with higher long-term mortality compared with patients with typical isolated chest pain. Similar trends were observed in STEMI and NSTEMI populations.

CONCLUSIONS

Atypical clinical presentation is observed in about 20% of AMI patients. Cardiac arrest, dyspnea, and syncope represent independent predictors of long-term mortality in STEMI and NSTEMI populations.

Typical angina is associated with greater coronary endothelial dysfunction but not abnormal vasodilatory reserve

BACKGROUND

Typical angina (TA) is defined as substernal chest pain precipitated by physical exertion or emotional stress and relieved with rest or nitroglycerin. Women and elderly patients are usually have atypical symptoms both at rest and during stress, often in the setting of nonobstructive coronary artery disease (CAD).

HYPOTHESIS

To further understand this, we performed subgroup analysis comparing subjects who presented with TA vs nontypical angina (NTA) using baseline data of patients with nonobstructive CAD and coronary microvascular dysfunction (CMD) enrolled in a clinical trial.

METHODS

155 subjects from the RWISE study were divided into 2 groups based on angina characteristics: TA (defined as above) and NTA (angina that does not meet criteria for TA). Coronary reactivity testing (responses to adenosine, acetylcholine, and nitroglycerin), cardiac magnetic resonance-determined myocardial perfusion reserve index (MPRI), baseline Seattle Angina Questionnaire (SAQ), and Duke Activity Status Index (DASI) scores were evaluated.

RESULTS

The mean age was 55 ± 10 years; Overall, 30% of subjects had TA. Baseline shortness of breath, invasively assessed acetylcholine-mediated coronary endothelial function, and SAQ score were worse in the TA group (all P < 0.05), whereas adenosine-mediated coronary flow reserve, MPRI, and DASI score were similar to the NTA group.

CONCLUSIONS

Among subjects with CMD and no obstructive CAD, those with TA had more angina pectoris, shortness of breath, and worse quality of life, as well as more severe coronary endothelial dysfunction. Typical angina in the setting of CMD is associated with worse symptom burden and coronary endothelial dysfunction. These results indicate that TA CMD subjects represent a relatively new CAD phenotype for future study and treatment trials.

Coronary artery disease presenting with left upper quadrant pain in a patient with chronic cervical tetraplegia

INTRODUCTION

This single-subject case report aims to describe and discuss a case of a patient with established C5 tetraplegia with acute coronary syndrome presenting with left upper quadrant pain and tenderness.

CASE PRESENTATION

A 65-year-old male with chronic C5 American Spinal Injury Association Impairment Scale (AIS) A tetraplegia presented to the emergency department with severe left upper quadrant pain radiating across the chest to the right upper limb with associated dyspnoea and diaphoresis. Prior to his emergency department admission, he had experienced progressive worsening of left upper quadrant pain and tenderness over several months. He was a non-smoker and swam regularly. He underwent coronary angiography and was found to have significant coronary artery disease. Drug-eluting stents were placed to critical coronary artery lesions followed by an uneventful hospital course with complete symptom resolution and discharge home.

DISCUSSION

Patients with tetraplegia are known to have higher rates of cardiovascular disease compared to ambulatory patients. Their cardiovascular risk profile may include atypical risk factors, for example, sleep disordered breathing, relative immobility and autonomic dysfunction. A high index of suspicion for cardiac pathology is warranted in those with cervical tetraplegia with persistent 'atypical' symptoms, including within the abdomen (especially when no specific abdominal organ dysfunction is evident). Sleep apnoea and significantly impaired mobility are potential cardiac risk factors in this patient group and should alert the emergency physician to cardiac disease (as in this case) irrespective of their complex past medical history and symptomatology.

Gender, race and the presentation of acute coronary syndrome and serious cardiopulmonary diagnoses in ED patients with chest pain

OBJECTIVE

To assess the relationship between reported chest pain symptoms and a diagnosis of acute coronary syndrome (ACS) and serious cardiopulmonary diagnoses (SCPD) in black males, white males, black females and white females.

METHODS

This was a secondary analysis of a prospective cohort study of 4162 ED patients with chest pain enrolled between 1999 and 2008. We used logistic regression, adjusting for age and cardiovascular comorbidities to test the association between 24 chest pain symptoms and 30-day ACS for the primary outcome and SCPD as the secondary outcome.

RESULT

In black males, diaphoresis was associated with ACS (OR 1.47; 95% CI 1.02 to 2.13), while in white males, left arm radiation, pressure/tightness and substernal pain were associated with ACS (OR 1.73, 95% CI 1.16 to 2.59; OR 1.65, 95% CI 1.16 to 2.59; OR 1.51, 95% CI 1.07 to 2.11, respectively). In black females, diaphoresis, palpitations and left arm radiation were associated with ACS (OR 1.66, 95% CI 1.17 to 2.35; 1.66, 95% CI 1.13 to 2.45; 1.44, 95% CI 1.02 to 2.03, respectively) while pleuritic pain, and left anterior chest pain lowered ACS risk (OR 0.69, 95% CI 0.5 to 0.96; 0.54, 95% CI 0.35 to 0.84). No symptoms predicted ACS or SCPD in white females. Fewer but similar symptoms predicted SCPD in white males and black females. No symptoms predicted SCPD in black males.

CONCLUSION

Chest pain symptoms are important predictors of ACS and SCPD in certain combinations of race and gender but less so in others. These differences might explain difficulties using symptoms to identify patients at higher or lower risk of ACS and SCPD in practice.

Symptom Trajectories After an Emergency Department Visit for Potential Acute Coronary Syndrome

BACKGROUND

Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) continue to experience troubling symptoms after discharge-regardless of their ultimate medical diagnosis. However, comprehensive understanding of common post-ED symptom trajectories is lacking.

OBJECTIVES

The aim of this study was to identify common trajectories of symptom severity in the 6 months after an ED visit for potential ACS.

METHODS

This was a secondary analysis of data from a larger observational, prospective study conducted in five U.S. EDs. Patients (N = 1005) who had electrocardiogram and biomarker testing ordered, and were identified by the triage nurse as potentially having ACS, were enrolled. Symptom severity was assessed in the hospital after initial stabilization and by telephone at 30 days and 6 months using the validated 13-item ACS Symptom Checklist. Growth mixture modeling was used for the secondary analysis. The eight most commonly reported symptoms (chest discomfort, chest pain, chest pressure, light-headedness, shortness of breath, shoulder pain, unusual fatigue, and upper back pain) were modeled across the three study time points. Models with increasing numbers of classes were compared, and final model selection was based on a combination of interpretability, theoretical justification, and statistical fit indices.

RESULTS

The sample was 62.6% male with a mean age of 60.2 years (SD = 14.17 years), and 57.1% ruled out for ACS. Between two and four distinct trajectory classes were identified for each symptom. The seven different types of trajectories identified across the eight symptoms were labeled "tapering off," "mild/persistent," "moderate/persistent," "moderate/worsening," "moderate/improving," "late onset, "and "severe/improving." Trajectories differed on age, gender, and diagnosis.

DISCUSSION

Research on the individual nature of symptom trajectories can contribute to patient-centered, rather than disease-centered, care. Further research is needed to verify the existence of multiple symptoms trajectories in diverse populations and to assess the antecedents and consequences of individual symptom trajectories.

Association between comorbidities and absence of chest pain in acute coronary syndrome with in-hospital outcome

BACKGROUND

To evaluate the impact of comorbidities on the management and outcomes of acute coronary syndrome (ACS) patients without chest pain/discomfort (i.e. ACS without typical presentation).

METHODS

Of the 11,458 ACS patients, enrolled by the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC; ClinicalTrials.gov: NCT01218776), 8.7% did not have typical presentation at the initial evaluation, and 40.2% had comorbidities. The odds of atypical presentation increased proportionally with the number of comorbidities (odds ratio [OR]: 1, no-comorbid; OR: 1.64, 1 comorbidity; OR: 2.52, 2 comorbidities; OR: 4.57, ≥3 comorbidities).

RESULTS

Stratifying the study population by the presence/absence of comorbidities and typical presentation, we found a decreasing trend for use of medications and percutaneous intervention (OR: 1, typical presentation and no-comorbidities; OR: 0.70, typical presentation and comorbidities; OR: 0.23, atypical presentation and no-comorbidities; OR: 0.18, atypical presentation and comorbidities). On the opposite, compared with patients with typical presentation and no-comorbidities (OR: 1, referent), there was an increasing trend (p<0.001) in the risk of death (OR: 2.00, OR: 2.52 and OR: 4.83) in the above subgroups. However, after adjusting for comorbidities, medications and invasive procedures, atypical presentation was not a predictor of in-hospital death. Independent predictors of poor outcome were history of stroke (OR: 2.04), chronic kidney disease (OR: 1.57), diabetes mellitus (OR: 1.49) and underuse of invasive procedures.

CONCLUSIONS

In the ISACS-TC, atypical ACS presentation was often associated with comorbidities. Atypical presentation and comorbidities influenced underuse of in-hospital treatments. The latter and comorbidities are related with poor in-hospital outcome, but not atypical presentation, per se.

Magnitude, treatment, and impact of diabetes mellitus in patients hospitalized with non-ST segment elevation myocardial infarction: A community-based study

PURPOSE OF THE STUDY

To examine differences in the characteristics, treatment practices and in-hospital outcomes of patients with and without previously diagnosed diabetes hospitalized for non-ST segment elevation myocardial infarction.

KEY METHODS

The study cohort consisted of 3916 patients diagnosed with non-ST segment elevation myocardial infarction at all 11 central MA medical centres between 1999 and 2009, of whom 1475 (38%) had been previously diagnosed with diabetes.

MAIN RESULTS

Diabetic patients were more likely to have received treatment with effective cardiac medications, and to have undergone coronary bypass surgery, but were less likely to have received a percutaneous coronary intervention, than non-diabetic patients. Patients with a history of diabetes were more likely to have developed cardiogenic shock, heart failure and died during their index hospitalization than non-diabetic patients.

MAIN CONCLUSION

Diabetic patients presenting with non-ST segment elevation myocardial infarction remain at high risk of developing significant clinical complications during hospitalization.

Performance of reperfusion therapy and hospital mortality in ST-elevation myocardial infarction patients with non-chest pain complaints

PURPOSE

ST-elevation myocardial infarction (STEMI) patients may visit the emergency department (ED) complaining of sensations of pain other than the chest. We investigated our performance of reperfusion therapy for STEMI patients presenting with non-chest pains.

MATERIALS AND METHODS

This was a retrospective observational cohort study. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were divided into a chest pain group and a non-chest pain group. Clinical differences between the two groups and the influence of presenting with non-chest pains on door-to-electrocardiograms (ECG) time, door-to-balloon time, and hospital mortality were evaluated.

RESULTS

Of the 513 patients diagnosed with STEMI, 93 patients presented with non-chest pains. Patients in the non-chest pain group were older, more often female, and had a longer symptom onset to ED arrival time and higher Killip class than patients in the chest pain group. There was a statistically significant delay in door-to-ECG time (median, 2.0 min vs. 5.0 min; p<0.001) and door-to-balloon time (median, 57.5 min vs. 65.0 min; p<0.001) in patients without chest pain. In multivariate analysis, presenting with non-chest pains was an independent predictor for hospital mortality (odds ratio, 2.3; 95% confidence interval, 1.1-4.7). However, door-to-ECG time and door-to-balloon time were not factors related to hospital mortality.

CONCLUSION

STEMI patients presenting without chest pain showed higher baseline risk and hospital mortality than patients presenting with chest pain. ECG acquisition and primary PCI was delayed for patients presenting with non-chest pains, but not influencing hospital mortality. Efforts to reduce pre-hospital time delay for these patients are necessary.

The prognostic implications of lack of palpitations in patients hospitalised with atrial fibrillation: observations from a 20-year registry

OBJECTIVES

It is well recognised that patients differ in the clinical presentation of atrial fibrillation (AF), ranging from the typical symptom of palpitations, atypical symptoms in others and a substantial that are asymptomatic. Whether the different patterns of presentation are associated with differences in outcomes is not known. The aim of this study was to evaluate the prevalence and the prognostic implications of lack of palpitations among patients hospitalised with AF in a large prospective registry.

METHODS

Retrospective analysis of all patients hospitalised with AF in Qatar from 1991 to 2010 was made. Patients were divided into two groups according to the presence or absence of palpitations on presentation. Clinical characteristics and outcome were analysed.

RESULTS

During the 20-year period, 3850 patients were hospitalised for AF; 1724 (44.8%) had palpitations on presentation while 2126 (55.2%) had no palpitations. Patients who lacked palpitations were 9 years older, had a higher prevalence of diabetes mellitus (64.7% vs. 35.3%), underlying coronary artery disease (CAD; 14.6% vs. 6.2%) and severe left ventricular dysfunction on echocardiography (25.5% vs. 6.6%), (all, p = 0.001). There were 141 deaths among the group with no palpitations compared with 19 among the group with palpitations (6.6% vs. 1.1%). Multivariate analysis of mortality predictors identified 'lack of palpitations' as an independent predictor of in-hospital mortality (relative risk 5.56; 95% confidence interval 1.20-25.0, p = 0.03).

CONCLUSIONS

Our study demonstrates for the first time that lack of palpitations as the presenting symptom of patients with AF is associated with worse in-hospital outcome independent of other risk factors or therapy. The underlying mechanisms and the role of confounders warrant further investigation.

Mortality trends in women and men presenting with acute coronary syndrome: insights from a 20-year registry

BACKGROUND

Coronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar.

METHODS

Data were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991-2010) and were analyzed according to gender.

RESULTS

Among 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27-1.79).

CONCLUSIONS

Women presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.

Myocardial infarction: sex differences in symptoms reported to emergency dispatch

BACKGROUND

Emergency management of myocardial infarction (MI) is time-critical, because improved patient outcomes are associated with reduced time from symptom onset to definitive care. Previous studies have identified that women are less likely to present with chest pain.

OBJECTIVE

We sought to measure the effect of sex on symptoms reported to the ambulance dispatch and ambulance times for MI patients.

METHODS

The Western Australia Emergency Department Information System (EDIS) was used to identify patients with emergency department (ED) diagnoses of MI (ST-segment elevation MI and non-ST-segment elevation MI) who arrived by ambulance between January 1, 2008, and October 31, 2009. Their emergency telephone calls to the ambulance service were transcribed to identify presenting symptoms. Ambulance data were used to examine ambulance times. Sex differences were analyzed using descriptive and age-adjusted regression analysis.

RESULTS

Of 3,329 MI patients who presented to Perth EDs, 2,100 (63.1%) arrived by ambulance. After predefined exclusions, 1,681 emergency calls were analyzed. The women (n = 621; 36.9%) were older than the men (p < 0.001) and, even after age adjustment, were less likely to report chest pain (odds ratio [OR] = 0.70; 95% confidence interval [CI] 0.57, 0.88). After age adjustment, ambulance times did not differ between the male and female patients with chest pain. The women with chest pain were less likely than the men with chest pain to be allocated a "priority 1" (lights and sirens) ambulance response (men 98.3% vs. women 95.5%; OR = 0.39; 95% CI 0.18, 0.87).

CONCLUSION

Ambulance dispatch officers (and paramedics) need to be aware of potential sex differences in MI presentation in order to ensure appropriate ambulance response.

Gendered symptom presentation in acute coronary syndrome: a cross sectional analysis

BACKGROUND

The international literature suggests that the symptom presentation of acute coronary syndrome may be different for men and women, yet no definitive conclusion about the existence of gendered presentation in ACS has been provided.

OBJECTIVE

This study examines whether gendered symptom presentation exists in a well-defined sample of men and women with ACS.

DESIGN AND SETTING

A cross-sectional analysis of baseline data pertaining to symptom experience and medical profiles were recorded for all ACS patients who participated in a multi-centered randomized control trial, in 5 hospitals, in Dublin, Ireland.

PARTICIPANTS

: Patients were deemed eligible if they were admitted through the Emergency Department (ED) with a diagnosis of ACS, if they were at least 21 years of age and able to read and converse in English. Patients were excluded if they had serious co-morbidities, cognitive, hearing or vision impairment.

METHODS

Patients were interviewed 2-4 days following their ACS event and data was gathered using the ACS response to symptom index.

RESULTS

The study included 1947 patients of whom 28% (n=545) were women. Chest pain was the most commonly experienced symptom in men and women, reported by 71% of patients. Using logistic regression and adjusting for clinical and demographic variables, women had greater odds of experiencing shortness of breath (50% vs 43%; odds ratio [OR]=1.32; 95% CI=1.08-1.62; p=.006) palpitations (5.5% vs 2.8%; OR=2.17; CI=1.31-3.62; p=.003) left arm pain (34% vs 30.5%; OR=1.27; CI=1.02-1.58; p=.03) back pain (7.5% vs 4.8%; OR=1.56; CI=1.03-2.37; p=.034) neck or jaw pain (21.5% vs 13.8%; OR=1.84; CI=1.41-2.40; p=.001) nausea (28% vs 24%; OR=1.30; CI=1.03-1.65; p=.024) a sense of dread (13.4% vs 10.5%; OR=1.47; CI=1.08-2.00; p=.014) and fatigue (29% vs 21.5%; OR=1.64; CI=1.29-2.07; p=.001) than their male counterparts.

CONCLUSIONS

Although chest pain is the most commonly experienced symptom by men and women, other ACS symptomology may differ significantly between genders.