Clinical Impact of Atypical Chest Pain and Diabetes Mellitus in Patients with Acute Myocardial Infarction from Prospective KAMIR-NIH Registry.

Jun–Won Lee ,Kwang Soo ,Sang Jun Lee ,Myung Ho Jung ,Dae Ryong Kang ,Byung‐Su Yoo ,Min‐Soo Ahn ,Dong‐Ju Choi ,Myeng-Chan Cho ,Seung Hwan Lee ,Shung Chull Chae ,Byoung Geol Choi ,Seung Ho Hur ,Sung Gyun Ahn ,Ju Han Kim ,In Whan Seong ,Seok Kyu Oh ,Jong Seon Park ,Jang Young Kim ,Jin Yong Hwang ,Young Jin Youn ,Jei Keon Chae ,Jung–Woo Son ,Ju Hyung Moon ,Junghan Yoon

doi:10.3390/jcm9020505

Abstract

Atypical chest pain and diabetic autonomic neuropathy attract less clinical attention, leading to underdiagnosis and delayed treatment. To evaluate the long-term clinical impact of atypical chest pain and diabetes mellitus (DM), we categorized 11,159 patients with acute myocardial infarction (AMI) from the Korea AMI-National Institutes of Health between November 2011 and December 2015 into four groups (atypical DM, atypical non-DM, typical DM, and typical non-DM). The primary endpoint was defined as patient-oriented composite endpoint (POCE) at 2 years including all-cause death, any myocardial infarction (MI), and any revascularization. Patients with atypical chest pain showed higher 2-year mortality than those with typical chest pain in both DM (29.5% vs. 11.4%, p < 0.0001) and non-DM (20.4% vs. 6.3%, p < 0.0001) groups. The atypical DM group had the highest risks of POCE (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.48–2.10), all-cause death (HR 2.23, 95% CI 1.80–2.76) and any MI (HR 2.34, 95% CI 1.51–3.64) in the adjusted model. In conclusion, atypical chest pain was significantly associated with mortality in patients with AMI. Among four groups, the atypical DM group showed the worst clinical outcomes at 2 years. Application of rapid rule in/out AMI protocols would be beneficial to improve clinical outcomes.

Highlights

Chest pain is one of the cardinal symptoms that warrants a visit to the emergency department (ED) [1]
Patients diagnosed with acute myocardial infarction (AMI) in 20 tertiary hospitals from November 2011 to December 2015 were enrolled in the study
Dyspnea was more frequently associated with atypical chest pain

Summary

Introduction

Chest pain is one of the cardinal symptoms that warrants a visit to the emergency department (ED) [1]. Among patients with chest pain, those with pain of cardiac origin consist of a quarter to a third of the total burden [1,2]. It is challenging to determine whether chest pain is related to acute coronary syndrome (ACS). The atypical features of chest pain of non-cardiac origin are considered less urgent and tend to be overlooked and underestimated. Delayed diagnosis and treatment of these patients, who were eventually diagnosed with acute myocardial infarction (AMI), have known to be associated with unfavorable clinical outcomes [2,5,6,7]

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Discussion

Conclusion