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    Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. 2004

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    Authors
    Brieger, David
    Eagle, Kim A.
    Goodman, Shaun G.
    Steg, Phillippe Gabriel
    Budaj, Andrzej
    White, Kami
    Montalescot, Gilles
    GRACE Investigators
    UMass Chan Affiliations
    Center for Outcomes Research
    Document Type
    Journal Article
    Publication Date
    2009-11-01
    Keywords
    Acute Disease
    Chest Pain
    Coronary Disease
    Diagnostic Errors
    History, 20th Century
    Humans
    Medical Receptionists
    Registries
    Treatment Outcome
    Cardiovascular Diseases
    Health Services Research
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    Link to Full Text
    http://dx.doi.org/10.1378/chest.126.2.461
    Abstract
    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.
    Source
    Chest. 2009 Nov;136(5 Suppl):e30.
    Permanent Link to this Item
    http://hdl.handle.net/20.500.14038/27282
    PubMed ID
    20162779
    Notes

    Originally published: Chest. 2004 Aug;126(2):461-9. Highlighted in Chest's 75th Commemorative Edition supplement in November 2009 as one of 75 seminal studies published in the journal since the first issue in March 1935. The top 75 are listed in a special online collection at www.chestjournal.org/content/136/5_suppl.

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