Japanese patients with acute myocardial infarction who present without chest pain

Previous studies have suggested that patients with acute myocardial infarction (AMI) who presented without chest pain had an unfavorable prognosis due to undertreatment. Despite this, few studies have been conducted on the topic, particularly in Japan. The present analysis aimed at determining whether Japanese AMI patients without chest pain are undertreated and experience higher mortality during hospitalization. Data from the Tokai Acute Myocardial Infarction Study II sample were used, which is a prospective study of all consecutive patients admitted to the 15 acute care hospitals in the Tokai region with the diagnosis of AMI from 2001 to 2003. Data on baseline and procedural characteristics and hospital outcome were collected. Differences in the baseline and procedural characteristics and clinical outcomes between patients presenting with and without chest pain were assessed. We evaluated a total of 1,769 patients who presented with chest pain and 452 who did not. The patients with AMI in the absence of chest pain were older and were more likely to have worse clinical conditions than those with chest pain. They were more likely to be undertreated, although the probability of vasopressor use was higher. The patients without chest pain had a significantly higher in-hospital mortality rate than those with chest pain. According to multivariate analysis, however, chest pain was not identified as an independent predictor of in-hospital death. The results suggest that the higher in-hospital mortality rate among Japanese AMI patients without chest pain could be accounted for by differences in clinical conditions.     

HEART风险评分在非心肌梗死性胸痛人群的研究

目的:研究HEART风险评分在非急性心肌梗死性胸痛人群的应用价值。方法:这是一个源于前瞻性获得的数据库的回顾性研究。连续入选2014年9月至2015年2月,在北京安贞医院急诊胸痛中心就诊的胸痛患者。计算HEART评分。研究终点为3个月时主要不良心脏事件。结果:研究总计入选1041名胸痛患者。其中,332名患者发生了主要不良心脏事件。HEART评分的受试者操作特征曲线下面积为0.77(95%CI:0.74~0.80)。随评分增加,主要不良心脏事件显著增加(P0.001)。入选的所有患者分成三组:低危组(评分0~2分),中危组(评分3~4分)和高危组(评分5~8分),主要不良心脏事件发生率分别为1.7%,17.1%和54.6%,各组间差异有统计学意义(P0.001)。不同的组别,给予不同的分诊方案。结论:HEART风险评分可以用于急诊科非急性心肌梗死性胸痛患者的分诊和预后评估。     

Management of patients with prolonged ischemic chest pain without acute myocardial infarction

Consecutive patients admitted to a Coronary Care Unit during 1981-1982 were studied. One hundred twenty-eight patients had prolonged ischemic chest pain without developing myocardial infarction. Follow-up information was available in 121 at an average period of 38 months. Thirty-eight patients (32.8%) sustained significant cardiovascular events, including 14 cardiac deaths. Only 15 patients were symptom-free off treatment. Prognosis was best determined from the resting ECG. Transient ST-T wave shifts predicted patients at high risk of further cardiovascular events and allowed selection of a group meriting more intensive treatment.     

痛性和无痛性心肌梗死患者临床特征的对比观察

目的　探讨痛性心肌梗死 (CPMI)和无痛性心肌梗死 (NCPMI)患者的临床特征。方法　将 43 6例AMI患者根据发病前有无胸痛主诉分成无胸痛组 (NCPMI组 ) 14 1例和有胸痛组(CPMI组 ) 2 95例。结果　 (1)NCPMI组发病年龄较大 [(70 .2 4± 9.82 )岁比 (62 .3 1± 8.3 5 )岁 ,P <0 .0 1] ,女性占的比例较大 (4 4 .68%比 3 2 .3 0 % ,P <0 .0 1) ,伴有糖尿病 (DM )者较多 (3 4.75 %比2 0 .3 4% ,P <0 .0 0 1) ,既往有心功能不全史较多 (2 3 .40 %比 10 .85 % ,P <0 .0 0 1) ;(2 )NCPMI组来院诊治时间晚 [(7.95± 2 .43 )h比 (5 .3 1± 1.2 2 )h ,P <0 .0 0 1] ,接受静脉溶栓治疗者较少 (2 5 .5 3 %比 5 7.2 9% ,P <0 .0 0 1) ,梗塞相关血管再通率低 (3 5 .46%比 47.46% ,P <0 .0 5 ) ,住院病死率较高(19.15 %比 9.49% ,P <0 .0 1)。结论　急性心肌梗死患者发病前不伴有胸痛症状者预后较有胸痛症状者差。     

Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain

OBJECTIVE—To describe the clinical features, prognosis, and treatment of patients presenting with atypical forms of acute myocardial infarction.
DESIGN—Consecutive cases of possible acute myocardial infarction were sought from coronary care registers, biochemistry records, and hospital management systems. Case notes were reviewed and predefined epidemiological and clinical variables were abstracted.
SETTING—20 adjacent hospitals in the former Yorkshire region.
PATIENTS—3684 consecutive cases of possible acute myocardial infarction admitted in a three month period were identified, of whom 2096 had a first episode of confirmed acute myocardial infarction.
RESULTS—20.2% of all patients admitted with an eventual diagnosis of acute myocardial infarction presented with symptoms other than chest pain. Compared with the group presenting with chest pain, these patients were older (76.6 v 69.1 years, p < 0.001), were more often women (54.6% v 35.3%, p < 0.001), and were more likely to have a history of heart failure (18.6% v 6.9%, p < 0.001). They had a higher 30 and 365 day mortality (49.2% and 61.0%, respectively) compared with patients presenting with chest pain (17.9% and 26.2%). In a Cox regression analysis the hazard ratio for presentation without chest pain was 1.60 (95% confidence interval 1.30 to 1.97) (p < 0.001) adjusted for age, heart rate, blood pressure, left ventricular impairment, and infarction with ST segment elevation as covariates. Importantly, they were also less likely to receive treatments with a proven ability to improve prognosis.
CONCLUSIONS—Atypical presentation of myocardial infarction without chest pain is common and associated with increased mortality. This may result in part from a failure to use beneficial treatment strategies.


Keywords: acute myocardial infarction; atypical presentation     

The diagnoses of patients admitted with acute chest pain but without myocardial infarction

OBJECTIVE: The purpose of this study was to describe the frequencies ofvarious diagnoses in patients admitted with acute chest pain,but without acute myocardial infarction, and to evaluate a non-invasivescreening programme for these patients. PATIENTS: A total of 204 consecutive non-acute myocardial infarction patientswere included. Fifty-six had a definite diagnosis within 48h, whereas 148 patients underwent an examination programme includingpulmonary scintigraphy, echocardiography, exercise electrocardiography,myocardial scintigraphy, Holter monitoring, hyperventilationtest, oesophago-gastro-duodenoscopy, 3 h monitoring of oesophagealpH, oesophageal manometry, Bernstein test, physical examinationof the chest wall and thoracic spine, bronchial histamine provocationtest and ultrasonic examination of the abdomen. RESULTS: According to predefined criteria, 186 patients (91%) had atleast one diagnosis, 144 had one, whereas 39 had two, and threepatients had three diagnoses. In 18 patients no diagnosis wasobtained. The diagnoses belonged mainly to three groups: (1)ischaemic heart disease (n=64); (2) gastro-oesophageal diseases(n=85); (3) chest-wall syndromes (n=58). Less frequent diagnosesincluded pulmonary embolism, pleuritis/pneumonia, lung cancer.aortic stenosis, aortic aneurysm and herpes zoster. CONCLUSIONS: The high risk subset of a non-acute myocardial infarction populationcan be identified by means of a clinical evaluation and non-invasivecardiac examinations. Among the remainder, pulmonary embolism,gastro-oesophageal diseases and chest-wall syndromes shouldbe paid special attention. A careful physical examination ofthe chest wall and an upper endoscopy seems to be the most cost-beneficialexamination to employ in this subset.     

Cocaine and chest pain: clinical features and outcome of patients hospitalized to rule out myocardial infarction

OBJECTIVE: To investigate the clinical features, electrocardiographic findings, and hospital course in patients admitted with acute chest pain temporally related to cocaine use. DESIGN: Retrospective data analysis. SETTING: A 485-bed county hospital. PATIENTS: One hundred and one consecutive patients with cocaine-related chest pain admitted to the hospital to rule out myocardial infarction. MEASUREMENTS AND MAIN RESULTS: The quality of the chest pain frequently suggested myocardial ischemia. Dyspnea was common (56%). The onset of chest pain occurred during cocaine use in 21% of patients, within 1 hour of use in 37%, and after 1 hour of use in 42%. Admission electrocardiographic findings were interpreted as normal in 32% of patients; as acute myocardial injury in 8%; as early repolarization variant in 32%; as left ventricular hypertrophy in 16%; and as "other" in 12%. Forty-three percent of patients had ST-segment elevation meeting the electrocardiographic criteria for use of thrombolytic therapy, but such elevation was usually due to the early repolarization variant. The initial total creatine kinase was elevated more than 3.3 mu kat/L (200 U/L) in 43% of patients, and an elevated total creatine kinase was recorded at some time during the hospital course in 47% of patients. The creatine kinase MB fraction was less than 0.02 in all patients. Myocardial infarction was ruled out in all patients. No patient experienced in-hospital cardiovascular complications. CONCLUSION: The quality of acute chest pain related to cocaine use is indistinguishable from that experienced in acute myocardial ischemia. Abnormal or normal variant electrocardiographic findings are common in patients with chest pain related to cocaine use, but nevertheless the incidence of acute myocardial infarction is low. The ST-segment and T-wave changes can mimic acute myocardial injury and are most likely normal findings in young black men that can be readily recognized in the emergency department. Most of these patients do not require admission to an intensive care unit.     

Prognosis and thallium-201 scintigraphy in patients admitted with chest pain without confirmed acute myocardial infarction

Exercise and rest thallium scintigraphy and exercise electrocardiography were performed after discharge in 158 patients aged less than 76 years admitted with chest pain in whom a suspected diagnosis of acute myocardial infarction had not been confirmed. During a follow up of 12-24 months (median 14 months) there were 10 cardiac events--that is, non-fatal acute myocardial infarction or cardiac deaths. Transient thallium defects and abnormal ST response (that is ST segment deviation or uninterpretable ST segment) during exercise were correlated significantly with an unfavourable prognosis. One hundred and four patients with neither of these characteristics were at lower risk of a cardiac event than the 19 patients with both of these characteristics. The percentages of patients in these two groups without a cardiac event after one year were 98.1 and 78.8 respectively. Thallium scintigraphy, alone or in combination with exercise electrocardiography, can be used to identify groups at high and low risk of future cardiac events, in patients with chest pain in whom acute myocardial infarction is suspected but not found.     

老年人2型糖尿病患者无胸痛性急性心肌梗死临床观察

目的观察老年2型糖尿病患者无胸痛性心肌梗死的临床特点。方法临床确诊的60岁以上老年人2型糖尿病无胸痛性心肌梗死患者作为观察组(A组,41例),老年2型糖尿病心肌梗死伴典型心绞痛患者(B组,49例)及非老年人2型糖尿病心肌梗死伴典型心绞痛患者作为对照组(C组,43例)。比较3组基线临床资料,发作至入院时间、急性心肌梗死发作时的主要临床表现、合并症、并发症、心电图特点,并比较院内病死率。结果 3组临床基线资料比较显示,A组较B、C组患者年龄大[(74±9)岁],糖尿病病程长[(18±5)年],合并疾病比例高,发作至入院诊时间长[(19±13)h](均为P<0.05)。C组男性较A、B组多(88.4%),A、B组间差异无统计学意义(均为P<0.05)。A组以呼吸困难、恶心呕吐、乏力、头晕为主要临床表现,室性心律失常较多见(34.1%)。ECG表现为ST段抬高型心肌梗死较少(31.7%)非sT段抬高型心肌梗死较多(48.8%),梗死部位为下壁(36.6%)和后壁(26.8%)较多。A组病死率为17.1%,B组为8.1%,C组为7.0%。A组病死率较B、C组高,有统计学意义(均为P<0.05)。结论老年人2型糖尿病无胸痛性心肌梗死患者年龄较大,糖尿病病程较长,合并疾病较多,临床症状多变,ECG表现为STEMI较少NSTEMI较多,梗死部位为下壁和后壁较多,病死率较高,临床应提高对其的认识。     

Acute myocardial infarction and chest pain syndromes after cocaine use

Seventy patients hospitalized with chest pain after cocaine use were retrospectively evaluated to define the risk and clinical course of acute myocardial infarction (AMI). AMI developed in 22 patients (31%) and transient myocardial ischemia was seen in an additional 9 patients (13%). Coronary risk factors did not distinguish those who developed AMI from those who did not. The presenting electrocardiogram was abnormal in 20 of 22 patients who evolved AMI and in 19 of 48 of those who did not. Creatine kinase levels were elevated in 75% of the patients, including 65% of those who did not develop AMI, but creatine kinase-MB elevations were only observed in the AMI group. The route of cocaine administration did not predict AMI and there was no predilection for a particular coronary vascular bed. The length of time between drug use and onset of AMI pain was often quite prolonged (median interval, 18 vs 1 hour in the non-AMI group). Eight of the patients with AMI underwent cardiac catheterization and 4 had significant coronary narrowing.     

Prognosis and thallium-201 scintigraphy in patients admitted with chest pain without confirmed acute myocardial infarction.

Exercise and rest thallium scintigraphy and exercise electrocardiography were performed after discharge in 158 patients aged less than 76 years admitted with chest pain in whom a suspected diagnosis of acute myocardial infarction had not been confirmed. During a follow up of 12-24 months (median 14 months) there were 10 cardiac events--that is, non-fatal acute myocardial infarction or cardiac deaths. Transient thallium defects and abnormal ST response (that is ST segment deviation or uninterpretable ST segment) during exercise were correlated significantly with an unfavourable prognosis. One hundred and four patients with neither of these characteristics were at lower risk of a cardiac event than the 19 patients with both of these characteristics. The percentages of patients in these two groups without a cardiac event after one year were 98.1 and 78.8 respectively. Thallium scintigraphy, alone or in combination with exercise electrocardiography, can be used to identify groups at high and low risk of future cardiac events, in patients with chest pain in whom acute myocardial infarction is suspected but not found.     

Patients with non-ST-elevation myocardial infarction and without chest pain are treated less aggressively and experience higher in-hospital mortality

BACKGROUND: Lack of chest pain or atypical pain does not exclude acute coronary syndrome (ACS). AIM: To assess demographic and clinical characteristic as well as treatment strategies in patients with atypical chest pain on admission in hospitals without on-site invasive facility (IF). METHODS: Twenty-nine community hospitals participated in the Registry of Acute Coronary Syndromes. A total of 2382 patients with ACS were enrolled. Patients admitted to hospitals with suspected ACS were stratified according to their pain symptoms as either typical (TS) or atypical which also included lack of pain (ATS). RESULTS: Of all patients with initial ACS diagnosis 152 (6.4%) presented without chest pain on admission. Patients from group ATS in comparison to group TS were more often women (49 vs. 39%; p=0.01), and less frequently had past medical history of coronary artery disease (54.3 vs. 72.5%; p <0.0001), myocardial infarction (15.2 vs. 32.1%; p <0.0001), arterial hypertension (65.6 vs. 74.5; p <0.0001) or renal insufficiency (1.3 vs. 5%; p=0.04). Invasive treatment was undertaken in 9.2% of patients from group ATS and in 14.6% from group TS (p=0.049). In-hospital mortality among all patients remaining in community hospitals for conservative treatment was similar in both groups (ATS vs. TS: 8.7 vs. 5.9%; p=NS). Among patients with typical and atypical symptoms the occurrence of ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) was similar. Patients with NSTEMI and UA with atypical symptoms were less likely transferred for invasive diagnostic, for NSTEMI 9.4 vs. 18.1% (p=0.03) and for UA 6.1 vs. 12.9% (p=0.04). In-hospital mortality was similar among typical and atypical groups in STEMI and UA patients. However, it was significantly higher among NSTEMI patients with atypical chest pain treated conservatively (3.6 vs. 0%; p=0.05). CONCLUSIONS: There is a significant group of ACS patients without chest pain on admission who are usually women with less severe past medical history. This subset of patients is treated less aggressively in terms of antiplatelet therapy and invasive approach. It is patients with diagnosis of NSTEMI who due to being misdiagnosed due to their atypical chest pain have poorer outcome.     

Time of onset of chest pain in acute myocardial infarction

We studied the time of onset of chest pain in 1099 patients admitted to a coronary care unit with myocardial infarction using a statistical model. Statistical analysis demonstrated an excess of infarcts with time of onset of chest pain at 0700 hours (14%) and at midnight (11%), with the remaining infarct population (75%) forming a background distribution over the 24 hr.     

Severe limb pain suppresses chest pain in a patient with anterior myocardial infarction

Cardiac complications of chest trauma range from arrhythmias and valvular avulsions to myocardial contusion, rupture, and-rarely-myocardial infarction. Herein, we described a 44-year-old male patient who presented to the hospital after receiving a blow from a fist directly to the chest and fingertip amputation during a fight; anterior myocardial infarction without any chest pain was coincidentally detected. Our case illustrates the importance of electrocardiography in the initial evaluation of patients with chest trauma and suspected injury to the coronary arteries.