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Recognising “painless” heart attacks
  1. C-K Wong,
  2. H D White
  1. Cardiovascular Research Unit, Green Lane Hospital, Private Bag 92 189, Auckland 1030, New Zealand
  1. Correspondence to:
    Professor White, Cardiovascular Research Unit, Green Lane Hospital, Private Bag 992 189, Auckland 1030, New Zealand;

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Heart attacks without chest pain all too often go unrecognised and untreated

Ischaemic chest pain has been the hallmark of the clinical presentation of patients with acute coronary syndromes. New modalities for early diagnosis and treatment have been developed (for example, rapid troponin assays, glycoprotein IIb/IIIa receptor antagonists, anticoagulants, and facilitated percutaneous intervention), and cardiologists are now extending their reach to the emergency department—the portal of the hospital—in order to ensure that reperfusion and adjunctive treatments are instituted with minimal delay.1 Yet there has been relatively little evaluation of modern treatments in the context of “silent” myocardial infarction, a well recognised entity described by Herrick in 19122 and documented further in long term follow up of the Framingham Study.3

A recent issue of Heart featured the results of the EMMACE study, an audit of patient records from 20 adjacent hospitals in the Yorkshire region over a three month period in the mid 1990s.4 The authors identified 3684 consecutive cases with a possible diagnosis of acute myocardial infarction based on coronary care registers, clinical coding, and cardiac enzyme test results. The diagnosis was confirmed in 2096 patients, 20% of whom had presented without chest pain. This proportion is somewhat higher than has been reported in previous studies,5,6 a finding the authors attribute to their retrospective methodology based on the final diagnosis of myocardial infarction, allowing identification of infarctions that were unexpected at presentation.4 In other words, many patients with “painless” infarction had an unexpected and often delayed diagnosis.

The patients who presented without chest pain were older (mean age 76.6 v 69.1 years) and were more likely to be female (54.6% v 35.3%) or to have a history of heart failure (61.0% v 49.2%). They also had worse baseline haemodynamics and more severe left …

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