Chest
Volume 126, Issue 2, August 2004, Pages 461-469
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Clinical Investigations
CARDIOLOGY
Acute Coronary Syndromes Without Chest Pain, An Underdiagnosed and Undertreated High-Risk Group: Insights From The Global Registry of Acute Coronary Events

https://doi.org/10.1378/chest.126.2.461Get rights and content

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.

Section snippets

Materials and Methods

The full details of the GRACE rationale and methodology have been published.1011 GRACE is designed to reflect an unbiased population of patients with ACSs, irrespective of geographic region. Currently, 95 hospitals located in 14 countries (ie, Argentina, Australia, Austria, Belgium, Brazil, Canada, France, Germany, Italy, New Zealand, Poland, Spain, the United Kingdom, and the United States) are participating in this observational study.

Patients enrolled in the registry had to be at least 18

Frequency of Atypical Symptoms

Over the period July 1999 to June 2002, 20,881 patients were admitted to the hospital with ACSs, of whom 1,763 (8.4%) presented with atypical symptoms. The dominant presenting symptoms in these patients were dyspnea in 869 (49.3%), diaphoresis in 462 (26.2%), nausea or vomiting in 426 (24.3%), and presyncope/syncope in 335 (19.1%) [Fig 1].

Patient Characteristics

Patients without chest pain were significantly older than those with typical symptoms. They were more likely to be women and to have a history of

Discussion

Although presentations with ACSs share common underlying pathophysiologic mechanisms, they offer a challenge from the standpoint of diagnosis, treatment, and prognosis because the clinical manifestations of these conditions vary considerably. Most episodes of ACSs are characterized predominantly by chest pain. However, a proportion of patients may have atypical, minimal, or no symptoms.

In our population, patients with atypical symptoms were more likely to be older, female, hypertensive, and

Conclusions

This analysis has shown that patients with acute coronary ischemia in the absence of chest pain are older and sicker than those with chest pain. The diagnosis is often made belatedly, and initial and subsequent hospital management is suboptimal. With the exception of diaphoresis, each dominant presenting symptom independently identifies a population that is at increased risk of dying. These patients represent a high-risk group, independent of whether their presentation is accompanied by

GRACE Co-Chairs

Keith A. Fox, The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK; and Joel M. Gore, University of Massachusetts Medical School, Worcester, MA.

GRACE Publication Committee Co-Chairs

Kim A. Eagle, University Hospital, Ann Arbor, MI; and P. Gabriel Steg, Hôpital Bichat, Paris, France.

Committee Members

Giancarlo Agnelli, University of Perugia, Perugia, Italy; Frederick A. Anderson Jr, University of Massachusetts Medical School, Worcester, MA; Álvaro Avezum, CTI-A Hospital Albert Einstein, São Paulo, Brazil; David Brieger, Concord Hospital, Sydney,

ACKNOWLEDGMENT

The authors of this report would like to express their gratitude to the physicians and nurses participating in GRACE. Further information about GRACE, along with a complete list of participants, is available at www.outcomes.org/grace.

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GRACE is supported by an unrestricted educational grant from Aventis Pharma, Bridgewater, NJ.

A complete list of investigators and institutions can be found in the Appendix.

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