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

Brieger, David; Eagle, Kim A.; Goodman, Shaun G.; Steg, Philippe Gabriel; Budaj, Andrzej; White, Kami; Montalescot, Gilles

doi:10.1378/chest.126.2.461

Cited by 452 publications

(406 citation statements)

References 25 publications

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“…The presence of heart failure increased significantly with increasing age as shown in other registries. 7,18,20 Similar to previous studies 2,19 our study demonstrated that elderly with MI were more likely to have NSTEMI and the proportion of STEMI decreased with increasing age. Also, Mehta et al, demonstrated that STEMI accounted only for 30% of all elderly patients admitted with ACS.…”

Section: Clinical Presentation and Acs Typesupporting

confidence: 87%

“…Consistent with findings from GRACE (Global registry of acute coronary events), 18 the risk of 12-month mortality increased with increasing patient age. After adjustment for patient and hospital factors, the odds ratio of 12-month mortality for older age groups compared with age 50 was 2.16 for patients aged 51e70 years, 4.10 for those aged >70 years (Table 4).…”

Section: Hospital Management and Outcomessupporting

confidence: 84%

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Age and clinical outcomes in patients presenting with acute coronary syndromes

Ahmed

AlHabib

El‐Menyar

et al. 2013

Journal of Cardiovascular Disease Research

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a b s t r a c tContext: Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients. Aims: To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS). Methods and material: Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: 50 years, 51e70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months. Statistical analysis used: One-way ANOVA test for continuous variables, Pearson chi-square (X 2 ) test for categorical variables and multivariate logistic regression analysis for predictors were performed. Results: Among 7930 consecutive ACS patients; 2755 (35%) were 50 years, 4110 (52%) were 51e70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients 50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03e1.60), heart failure (OR 2.8; 95% CI 2.17e3.52) and major bleeding (OR 4.02; 95% CI 1.37 e11.77) and in-hospital mortality (age 51e70: OR 2.67; 95% CI 1.86e3.85, and age >70: OR 4.71; 95% CI 3.11e7.14). Conclusion: Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.

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Section: Clinical Presentation and Acs Typesupporting

confidence: 87%

Section: Hospital Management and Outcomessupporting

confidence: 84%

Age and clinical outcomes in patients presenting with acute coronary syndromes

Ahmed

AlHabib

El‐Menyar

et al. 2013

Journal of Cardiovascular Disease Research

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“…Canto et al (2000) reported that patients presenting with MI in the absence of chest pain are older than those presenting with chest pain (74.2 vs. 66.9 years). Brieger et al (2004) also found that patients who present without chest pain are significantly older than those who present with chest pain.…”

Section: Discussionmentioning

confidence: 86%

“…In another study, patients with diabetes experienced less nausea, more hyperventilation, and less aching and squeezing-type pain during an episode of unstable angina (DeVon, Penckofer, & Zerwic, 2005). Brieger et al (2004) found that atypical symptoms of ACS-including dyspnea, diaphoresis, syncope, and nausea and vomiting-occurred more frequently in patients with diabetes in the absence of chest pain. Mayer and Rosenfeld (2006) examined the role of diabetes in symptom interpretation in a sample of women with MI.…”

Section: Diabetes Can and Silent Myocardial Ischemiamentioning

confidence: 97%

Midwest Nursing Research Society Sage Best Paper Award: The Association of Diabetes and Older Age With the Absence of Chest Pain During Acute Coronary Syndromes

2007

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Cardiac autonomic neuropathy associated with diabetes can cause silent myocardial ischemia and may influence the way that patients perceive symptoms of acute coronary syndromes (ACS). The purpose of this study was to examine symptoms of ACS in patients with and without diabetes while controlling for length of time with diabetes. A convenience sample of 256 patients from two large medical centers in the Midwest participated. Patients with diabetes comprised 33.2% of the sample and reported significantly less chest pain and more unusual fatigue. Patients with diabetes of longer duration (10 or more years) reported more difficulty breathing than did patients with diabetes of shorter duration (fewer than 10 years). Older patients with the same diabetes status also reported less chest pain. For older patients and for patients with diabetes, lack of chest pain during ACS could delay treatment and is thus a concern.Keywords diabetes mellitus; acute coronary syndromes; myocardial ischemia; symptoms Diabetes is the fifth-leading cause of death in the United States. Over 65% of these deaths are attributed to cardiovascular disease (American Diabetes Association, n.d.). Diabetes confers a two-to fivefold greater risk of cardiac mortality for women and a threefold greater risk of cardiac mortality for men as compared to age and sex-matched persons without diabetes (Blendea, McFarlane, Isenovic, Gick, & Sowers, 2003). Increased mortality has been linked to a greater prevalence of silent ischemia associated with diabetes (Chico, Tomas, & Novials, 2005). It has been suggested that one mechanism of silent ischemia is cardiac autonomic neuropathy (CAN), which is a form of autonomic neuropathy involving damage to autonomic fibers, innervating blood vessels and the heart (Manzella & Paolisso, 2005). This damage may affect the afferent pathways that carry pain messages from the myocardium to the cerebral cortex, leading to diminished or absent chest pain during acute coronary syndromes (ACS; Langer, Freeman, Josse, Steiner, & Armstrong, 1991). Twenty-two percent of persons with type 2 diabetes have CAN, and silent ischemia occurs more frequently with diabetes in the presence of CAN (38%) as opposed to the absence of CAN (5%; Vinik, Freeman, & Erbas, 2003). The effects of CAN are not trivial. Manzella and Paolisso (2005) reported that mortality rates are 53% for those with CAN 5 years after diagnosis. Diabetes, CAN, and Silent Myocardial IschemiaThe consequences of silent ischemia can be grave because lack of symptoms and lack of symptom recognition can lead to delay in seeking immediate medical assistance during ACS and can be a factor in sudden cardiac death. There is limited research examining the cardiac symptoms reported by patients with diabetes who present with ACS. Funk, Naum, Milner, and Please address correspondence to Holli A. DeVon, PhD, RN; e-mail: hdevon@luc.edu. Other studies have found differences in cardiac symptoms, depending on diabetes status. Canto et al. (2000) noted that a higher proportion of patients...

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“…4 Because many patients with ACS in the emergency department (ED) are ''low suspicion'' (i.e., have neither chest pain nor a diagnostic ECG, as defined by high-risk findings such as ischemic ST-segment elevation, depression, T-wave inversion), biomarkers can help physicians to identify ACS and to stratify risk. [5][6][7][8][9] Because biomarkers are assessed in a central hospital laboratory outside the ED, they are often the timelimiting step in diagnosis of ACS. 4,8,10,11 Cardiac-specific troponins reliably allow early identification of patients with acute myocardial infarction and are of critical prognostic value, especially troponin I (cTnI).…”

mentioning

confidence: 99%

Impact of Point‐of‐care Testing in the Emergency Department Evaluation and Treatment of Patients with Suspected Acute Coronary Syndromes

Renaud

Maison

Ngako

et al. 2008

Academic Emergency Medicine

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Objectives: To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED). Methods:This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level ‡ 0.10 lg ⁄ mL), and in those with low suspicion ACS (no chest pain and no ST deviation).Results: Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups.Conclusions: Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS. ACADEMIC EMERGENCY MEDICINE 2008; 15:216-224 ª 2008 by the Society for Academic Emergency MedicineKeywords: point-of-care systems, coronary artery disease, myocardial infarction, emergency medicine, troponin, randomized controlled trials R apid diagnosis of patients with high-risk non-ST elevation acute coronary syndromes (NSTEACSs) may be critical, as recent findings suggest that adverse outcomes increase with increasing time to coronary angiography and related treatment.1-3 The key components of risk stratification are patient symptoms,

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

Cited by 452 publications

References 25 publications

Age and clinical outcomes in patients presenting with acute coronary syndromes

Age and clinical outcomes in patients presenting with acute coronary syndromes

Midwest Nursing Research Society Sage Best Paper Award: The Association of Diabetes and Older Age With the Absence of Chest Pain During Acute Coronary Syndromes

Impact of Point‐of‐care Testing in the Emergency Department Evaluation and Treatment of Patients with Suspected Acute Coronary Syndromes

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