Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain

Objective To describe the clinical features, prognosis, and treatment of pa tients presenting with atypical forms of acute myocardial infarction. Design-Consecutive cases of possible acute myocardial infarction were sough t from coronary care registers, biochemistry records, and hospital manageme nt systems. Case notes were reviewed and predefined epidemiological and cli nical variables were abstracted. Setting-20 adjacent hospitals in the former Yorkshire region. Patients-3684 consecutive cases of possible acute myocardial infarction adm itted in a three month period were identified, of whom 2096 had a first epi sode of confirmed acute myocardial infarction. Results-20.2% of all patients admitted with an eventual diagnosis of acute myocardial infarction presented with symptoms other than chest pain. Compar ed with the group presenting with chest pain, these patients were older (76 .6 v 69.1 years, p < 0.001), were more often women (54.6% v 35.3%, p < 0.00 1), and were more likely to have a history of heart failure (18.6% v 6.9%, p < 0.001). They had a higher 30 and 365 day mortality (49.2% and 61.0%, re spectively) compared with patients presenting with chest pain (17.9% and 26 .2%). In a Cox regression analysis the hazard ratio for presentation withou t chest pain was 1.60 (95% confidence interval 1.30 to 1.97) (p < 0.001) ad justed forage, heart rate, blood pressure, left ventricular impairment, and infarction with ST segment elevation as covariates. Importantly, they were also less likely to receive treatments with a proven ability to improve pr ognosis. Conclusions-Atypical presentation of myocardial infarction without chest pa in is common and associated with increased mortality. This may result in pa rt from a failure to use beneficial treatment strategies.