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MI Without Chest Pain May Signal Adverse Outcomes

Elderly patients with acute MI often present with dyspnea rather than chest pain. To identify the clinical characteristics of elderly MI patients without chest pain, investigators studied data from 434,877 patients with confirmed MI who were enrolled in the industry-supported National Registry of Myocardial Infarction-2 (NRMI-2) from June 1994 to March 1998.

The average age (74) of the 142,445 patients without chest pain at the time of hospitalization was significantly older than that of the 292,432 patients with chest pain (67). In addition, compared to patients with chest pain, those without it were more often female (49 percent vs. 38 percent) and diabetic (33 percent vs. 25 percent); those without chest pain also experienced longer delays between symptom onset and hospital arrival (7.9 vs. 5.3 hours). Patients without chest pain were significantly less likely to receive evidence-based therapies (in particular, primary reperfusion for ST-elevation MI, aspirin, beta-blockers, or heparin) within 24 hours of presentation. Finally, patients without chest pain had a significantly higher mortality rate than did those with chest pain (23 percent vs. 9 percent). In multivariate analysis, presentation without chest pain was among the most significant independent predictors of in-hospital mortality (odds ratio, 2.21); even after adjustment for missed opportunities to provide evidence-based treatments, the OR was 1.59.

Comment: Although this study's results duplicate those of many prior studies, the size of the NRMI-2 database and, in particular, its usefulness in identifying opportunities to improve care of MI patients who present without chest pain are noteworthy. The findings are especially important for women, the elderly, diabetics, and those with histories of stroke or heart failure.

— KA Eagle

Published in Journal Watch Cardiology September 1, 2000

Citation(s):

Canto JG et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000 Jun 28 283 3223-3229.

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