Presenting Symptoms in Acute Myocardial Infarction – Temporal Trends

Introduction - Although typical chest pain is considered a cardinal clinical feature required for the diagnosis of acute myocardial infarction (AMI), many patients present with atypical complaints. The full extent and implication of this phenomenon is largely unknown.

Aim – To evaluate the possible relationship and temporal trends between the presenting symptoms and outcomes in patients with AMI.

Methods – We used the Acute Coronary Syndrome Israeli Survey (ACSIS) in order to compare patients who presented with typical chest pain to patients who presented with an atypical complaints – dyspnea, non-specific chest pain, arrhythmia or syncope. To examine the temporal trends we compared the period of 2000-2006 with the period of 2008-2016.

Results – During the period of 2000-2016, 10,793 patients with ACS were enrolled. Of them, 6751 patients (62%) presented with typical chest pain, 2120 (19%) with atypical complaints, and 1922 (17%) with both. Patients with typical chest pain were younger, more commonly males, had less comorbidities, sought medical contact and underwent PCI faster than patients with atypical complaints (p<0.001 for each). Compared with patients with atypical complaints, patients with typical chest pain displayed decreased in hospital, 30 day and 1 year mortality (2.3% Vs 7.5%, 2.9% Vs 8.8%,6.5% Vs 17.7% respectively, p<0.001). While 1 year mortality decreased significantly over the years in patients with typical chest pain (8.7% Vs 4.4%, p<0.001), it hasn`t changed significantly in patients who presented with atypical complaints (20.5% Vs 21.1%, p=0.9). These results were consistent among STEMI and Non-STE-ACS patients, separately.

Conclusion – ACS patients who present with typical chest pain have a favorable outcome compared with patients who present with atypical complaints. Moreover, ACS patients who presented with atypical complaints failed to show an improvement in outcome over the last 2 decades. Identification and improved guideline based therapy of these high-risk patients might improve their future outcome.