HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:
Guest Access | Sign In via User Name/Password

This Article Full Text Free Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (33) Citing Articles via Google Scholar Google Scholar Articles by Brieger, D. Articles by Montalescot, G. Search for Related Content PubMed PubMed Citation Articles by Brieger, D. Articles by Montalescot, G.

Acute Coronary Syndromes Without Chest Pain, An Underdiagnosed and Undertreated High-Risk Group^*

Insights From The Global Registry of Acute Coronary Events

David Brieger, MBBS, PhD; Kim A. Eagle, MD; Shaun G. Goodman, MD, MSc; P. Gabriel Steg, MD; Andrzej Budaj, MD, PhD; Kami White, MPH and Gilles Montalescot, MD, PhD; for the GRACE Investigators

^* From the University of Sydney (Dr. Brieger), Sydney, Australia; the University of Michigan Health System (Dr. Eagle), Ann Arbor, MI; the Canadian Heart Research Centre and Terrence Donnelly Heart Center (Dr. Goodman), Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada; Hôpital Bichat (Dr. Steg), Paris, France; Grochowski Hospital (Dr. Budaj), Warsaw, Poland; the University of Massachusetts Medical School (Dr. White), Worcester, MA; and Pitié-Salpêtrière Hospital (Dr. Montalescot), Paris, France. A complete list of investigators and institutions can be found in the ^Appendix.

Correspondence to: David Brieger, MBBS, PhD, Department of Cardiology, Concord Repatriation General Hospital, Hospital Rd, Concord, Sydney, NSW, Australia 2139; e-mail: davidb{at}email.cs.nsw.gov.au

Study objectives: The clinical manifestations of acute coronary syndromes (ACSs) vary, and patients present frequently with symptoms other than chest pain. In this analysis, a large contemporary database has been accessed to define the frequency, clinical characteristics, and outcomes of patients presenting without chest pain across different diagnostic categories of ACS.

Design and setting: The Global Registry of Acute Coronary Events is a multinational, prospective, observational study involving 14 countries.

Patients: Patients presenting to the hospital with a suspected ACS were stratified according to whether their predominant presenting symptoms included chest pain (ie, typical) or did not (ie, atypical). Demographics, medical history, hospital management, and outcomes were compared.

Measurements and results: Of the 20,881 patients in this analysis, 1,763 (8.4%) presented without chest pain, 23.8% of whom were not initially recognized as having an ACS. They were less likely to receive effective cardiac medications, and experienced greater hospital morbidity and mortality (13% vs 4.3%, respectively; p < 0.0001) than did patients with typical symptoms. After adjusting for potentially confounding variables, increased hospital mortality rates were noted in patients with dominant presenting symptoms of presyncope/syncope (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4 to 2.9), nausea or vomiting (OR, 1.6; 95% CI, 1.1 to 2.4), and dyspnea (OR, 1.4; 95% CI, 1.1 to 1.9), and in those with painless presentations of unstable angina (OR, 2.2; 95% CI, 1.4 to 3.5) and ST-segment elevation myocardial infarction (OR, 1.7; 95% CI, 1.2 to 2.2).

Conclusion: Patients with ACSs who present without chest pain are frequently misdiagnosed and undertreated. With the exception of diaphoresis, each dominant presenting symptom independently identifies a population that is at increased risk of dying. These patients experience greater morbidity and a higher mortality across the spectrum of ACSs.

Key Words: acute coronary syndrome • atypical presentation • management • outcomes

This article has been cited by other articles:

				C. Ebeling Barbier, T. Bjerner, L. Johansson, L. Lind, and H. Ahlstrom Myocardial Scars More Frequent Than Expected: Magnetic Resonance Imaging Detects Potential Risk Group J. Am. Coll. Cardiol., August 15, 2006; 48(4): 765 - 771. [Abstract] [Full Text] [PDF]

				S. Stern Symptoms Other Than Chest Pain May Be Important in the Diagnosis of "Silent Ischemia," or "The Sounds of Silence" Circulation, June 21, 2005; 111(24): e435 - e437. [Full Text] [PDF]

				J G F Cleland, A Torabi, and N K Khan Epidemiology and management of heart failure and left ventricular systolic dysfunction in the aftermath of a myocardial infarction Heart, May 1, 2005; 91(suppl_2): ii7 - ii13. [Abstract] [Full Text] [PDF]