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Systematic review
Chest pain symptoms during myocardial infarction in patients with and without diabetes: a systematic review and meta-analysis
  1. Abhinav Kumar1,
  2. Amrit Sanghera1,
  3. Balpreet Sanghera1,
  4. Tahira Mohamed2,
  5. Ariella Midgen3,
  6. Sophie Pattison4,
  7. Louise Marston5,
  8. Melvyn M Jones5
  1. 1UCL Medical School, London, UK
  2. 2King's College Hospital, London, UK
  3. 3Royal Brompton & Harefield NHS Foundation Trust, London, UK
  4. 4UCL Library Services UCL Medical School (Royal Free Campus), UCL, London, UK
  5. 5Research Department of Primary Care and Population Health, UCL, London, UK
  1. Correspondence to Dr Melvyn M Jones, Research Department of Primary Care and Population Health, UCL, London, WC1E 6BT, UK; melvyn.jones{at}


Objective Chest pain (CP) is key in diagnosing myocardial infarction (MI). Patients with diabetes mellitus (DM) are at increased risk of an MI but may experience less CP, leading to delayed treatment and worse outcomes. We compared the prevalence of CP in those with and without DM who had an MI.

Methods The study population was people with MI presenting to healthcare services. The outcome measure was the absence of CP during MI, comparing those with and without DM. Medline and Embase databases were searched to 18 October 2021, identifying 9272 records. After initial independent screening, 87 reports were assessed for eligibility against the inclusion criteria, quality and risk of bias assessment (Strengthening the Reporting of Observational Studies in Epidemiology and Newcastle–Ottawa criteria), leaving 22 studies. The meta-analysis followed Meta-analysis Of Observational Studies in Epidemiology criteria and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled ORs, weights and 95% CIs were calculated using a random-effects model.

Results This meta-analysis included 232 519 participants from 22 studies and showed an increased likelihood of no CP during an MI for those with DM, compared with those without. This was 43% higher in patients with DM in the cohort and cross-sectional studies (OR: 1.43; 95% CI: 1.26 to 1.62), and 44% higher in case–control studies (OR: 1.44; 95% CI: 1.11 to 1.87).

Conclusion In patients with an MI, patients with DM are less likely than those without to have presentations with CP recorded. Clinicians should consider an MI diagnosis when patients with DM present with atypical symptoms and treatment protocols should reflect this, alongside an increased patient awareness on this issue.

PROSPERO registration number CRD42017058223.

  • Diabetes Mellitus
  • Myocardial Infarction

Data availability statement

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  • Contributors All authors have been involved in this study and agreed to the final manuscript. MMJ is the study guarantor and led the study, the analysis and write-up, and is the corresponding author. AK was involved in data collection, analysis and write-up, and is the lead author. SP led the information search strategy, while LM led the statistical analysis. All other authors were involved in data collection and write-up.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.