A 63-year-old male with a past medical history of epilepsy, hypertension, and papillary thyroid carcinoma s/p left hemithyroidectomy presents with nausea and vomiting. The patient reports that, around 2:00 AM, he woke up from his sleep and began sweating and vomiting. These symptoms have continued intermittently since then, and the patient presents with his wife around 5:00 PM. He reports epigastric discomfort but denies any fevers, chills, chest pain, palpitations, or shortness of breath. An index ECG is obtained (Figure 1).
Interpretation:
Rate: 64 bpm; Rhythm: sinus rhythm with first degree AV block; Axis: normal; Intervals: long PR (225), normal QRS (106), normal QTc (422); P-waves: present; QRS complex: normal; ST Segment/T waves: STE in II, III, aVF, STD in I and aVL. STD in V2 with a large R wave (the large R wave is a posterior Q wave)
Upon seeing this ECG, the cardiac catheterization lab was immediately activated. The patient was hemodynamically stable with a blood pressure of 133/72 and heart rate of 84. The patient was afebrile. Labs were notable for a troponin of 48.4. The patient received an aspirin loading dose (325 mg PO) and was taken to the cath lab with cardiology.
Cardiac catheterization showed the left anterior descending (LAD) artery with 80% stenosis, left circumflex (LCx) artery with 70% diffuse stenosis, and the mid-right coronary artery (RCA) with 100% occlusion.
Discussion:
The patient denied ever having chest pain. Upon arrival to the emergency department (ED), he denied any current chest pain, shortness of breath, or palpitations. He also denied any previous chest pain, orthopnea, or any dyspnea on exertion. He even endorsed a good exercise tolerance to the cardiologist.
Although reported percentages of patients with acute coronary syndrome (ACS) presenting with chest pain vary, ranging from as low as 67% to as high as 94%, all studies agree that chest pain is the most common presenting symptom in ACS. However, what about patients, like ours, who do not present with chest pain?
Breiger et al. analyzed data from 20,881 patients across 14 countries, finding that 8.4% of patients presented without chest pain. These patients were more likely to be misdiagnosed, with 23.8% not initially recognized as having ACS. They were also less likely to receive effective cardiac medications and experienced higher in-hospital morbidity and mortality rates (13% vs. 4.3%, respectively; p < 0.0001) compared to those with typical chest pain. After adjusting for confounding variables, the study found that patients presenting with symptoms such as pre-syncope/syncope, nausea/vomiting, and dyspnea had increased hospital mortality rates. Specifically, the odds ratios (OR) for increased mortality were 2.0 for pre-syncope/syncope, 1.6 for nausea/vomiting, and 1.4 for dyspnea. Additionally, patients with painless presentations of unstable angina and STEMI had ORs of 2.2 and 1.7, respectively.
Coronado et al. investigated the impact of triage and outcomes in patients presenting to the emergency department with symptoms suggestive of acute coronary syndrome but without a complaint of pain. The study analyzed data from 10,783 subjects across 10 US hospitals. It found that 6.2% of patients with acute ischemia and 9.8% of those with acute myocardial infarction presented without pain. Compared to similar patients who presented with pain, patients with painless ischemia were older, were more commonly women, and had more cardiac-related diseases. The percentages of patients with acute myocardial infarction admitted to critical care units were 55.7% for those with pain and 38.8% for those without pain (p < .001), while the mortality rates were 4.3% for patients with pain and 8.5% for those without pain (p < .001).
Take Away Points:
While chest pain is the most common symptom of ACS, a significant proportion of patients - especially those who are older, female, or have comorbidities - may present with atypical symptoms such as dyspnea, nausea, vomiting, and syncope
All these patients should obtain STAT ECGs in triage.
Authored by Taylor Wahrenbrock, MD; Michael Hohl, MD; and Ari Edelheit, MD.
References:
Bhatt DL, Lopes RD, Harrington RA. Diagnosis and Treatment of Acute Coronary Syndromes: A Review [published correction appears in JAMA. 2022 May 03;327(17):1710. doi: 10.1001/jama.2022.6185]. JAMA. 2022;327(7):662-675. doi:10.1001/jama.2022.0358
Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126(2):461-469. doi:10.1378/chest.126.2.461
Coronado BE, Pope JH, Griffith JL, Beshansky JR, Selker HP. Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: a multicenter study. Am J Emerg Med. 2004;22(7):568-574. doi:10.1016/j.ajem.2004.09.001