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Atypical presentations among medicare beneficiaries with unstable angina pectoris*,

https://doi.org/10.1016/S0002-9149(02)02463-3Get rights and content

Abstract

Chest pain is a hallmark symptom in patients with unstable angina pectoris (UAP). However, little is known regarding the prevalence of an atypical presentation among these patients and its relation to subsequent care. We examined the medical records of 4,167 randomly sampled Medicare patients hospitalized with unstable angina at 22 Alabama hospitals between 1993 and 1999. We defined typical presentation as (1) chest pain located substernally in the left or right chest, or (2) chest pain characterized as squeezing, tightness, aching, crushing, arm discomfort, dullness, fullness, heaviness, pressure, or pain aggravated by exercise or relieved with rest or nitroglycerin. Atypical presentation was defined as confirmed UAP without typical presentation. Among patients with confirmed UAP, 51.7% had atypical presentations. The most frequent symptoms associated with atypical presentation were dyspnea (69.4%), nausea (37.7%), diaphoresis (25.2%), syncope (10.6%), or pain in the arms (11.5%), epigastrium (8.1%), shoulder (7.4%), or neck (5.9%). Independent predictors of atypical presentation for patients with UAP were older age (odds ratio 1.09, 95% confidence interval 1.01 to 1.17/decade), history of dementia (odds ratio 1.49, 95% confidence interval 1.10 to 2.03), and absence of prior myocardial infarction, hypercholesterolemia, or family history of heart disease. Patients with atypical presentation received aspirin, heparin, and β-blocker therapy less aggressively, but there was no difference in mortality. Thus, over half of Medicare patients with confirmed UAP had “atypical” presentations. National educational initiatives may need to redefine the classic presentation of UAP to include atypical presentations to ensure appropriate quality of care.

Section snippets

Patient selection:

We examined the medical records of 4,167 Medicare patients enrolled in the Alabama Unstable Angina Study with a confirmed diagnosis of UAP. These patients were hospitalized at 22 centers throughout the state of Alabama between January 1, 1993, and December 31, 1999. Patients receiving treatment at hospitals participating in this study were identified from Medicare Part A Standard Analytic (MEDPAR) files. We developed a stratified random sampling method based upon the following the International

Baseline and presenting characteristics:

Table 1 summarizes baseline and presenting characteristics of the typical and atypical UAP groups. Over half of patients with confirmed UAP in this study had atypical presentations. A slightly higher proportion of UAP women with atypical symptoms were older, but no important differences were found by ethnicity. Also, UAP patients with atypical presentations were less likely to have a history of MI, hypercholesterolemia, or family history of heart disease, but were more likely to have a history

Discussion

This analysis represents one of the largest in-depth studies to examine the presenting symptoms of patients hospitalized with UAP. Among Medicare patients with confirmed UAP, we found that over half had atypical presentations, and the predominant symptoms were shortness of breath, nausea, diaphoresis, and pain or discomfort localized to other areas of the body such as the arm, epigastrium, shoulder, neck, or jaw. Also, 1 in 7 of the patients with atypical presentations of UAP had atypical chest

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    Citation Excerpt :

    When the Framingham researchers discovered that 25% of the MIs in their cohort of patients had been diagnosed by routine office electrocardiograms (ECGs) after the actual event had long been completed, they postulated that these MIs were missed as a result of being “silent” or atypical.19 Inconsistent methods of defining atypical presentations, however, have resulted in widely varying estimates of their incidence, ranging from 6% to 52%.20–26 Nevertheless, these studies have identified several populations that are consistently more likely to present in an atypical fashion: women, the elderly, and nonwhite minorities.4,20,27

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This work was supported by Grant HS08843 from the Agency for HealthCare Research and Quality and conducted in cooperation with the Alabama Quality Assurance Foundation and the Centers for Medicare and Medicaid Services, Birmingham, Alabama.

*

This material was prepared by the Alabama Quality Assurance Foundation under a contract with the Centers for Medicare and Medicaid Services (CMS). Contents do not necessarily represent CMS policy.

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