Feature Story

One-third of heart attack patients delay seeking care because they don't have chest pain

Chest pain has long been considered the classic sign of a heart attack (acute myocardial infarction, AMI). However, a new study, which was supported in part by the Agency for Healthcare Research and Quality (HS08843), found that one-third of patients diagnosed with AMI did not experience chest pain. What's more, these patients arrived at the hospital 3 hours later (mean of 8 vs. 5 hours) than AMI patients with chest pain.

Patients who did not have chest pain also were less likely to be diagnosed with AMI at hospital admission (22 vs. 50 percent), suggesting that doctors still consider chest pain a hallmark sign of heart attack. Perhaps as a result of delayed hospital arrival, diagnosis, and fewer cardiac treatments, these patients were twice as apt to die in the hospital (23 vs. 9 percent) as AMI patients with chest pain.

To improve the outcomes of AMI patients without chest pain, the public and medical professionals should be educated that other symptoms besides chest pain can indicate a heart attack and that the absence of chest pain does not necessarily rule out an AMI, notes lead author, John G. Canto, M.D., M.S.P.H., of the University of Alabama, Birmingham. Dr. Canto and his colleagues observed 434,877 patients with confirmed AMI treated at 1,674 U.S. hospitals to determine the frequency with which AMI patients arrived at the hospital without chest pain and their subsequent care and outcomes. Data used in this research were drawn from the National Registry of Myocardial Infarction, the largest observational study to date of U.S. heart attack patients.

The study revealed that heart attack patients without chest pain were less apt to receive clot-busting therapy or angioplasty (25 vs. 74 percent), aspirin (60 vs. 85 percent), beta blockers (28 vs. 48 percent), or the anticoagulant heparin (53 vs. 83 percent). These patients had some different clinical features as well. On average, they were 7 years older than those with chest pain (74 vs. 67 years), were more likely to be female (49 vs. 38 percent), and were more likely to have diabetes mellitus (33 vs. 25 percent) or prior heart failure (26 vs. 12 percent). Although it is widely known that heart attack victims who have diabetes may not experience chest pain, these other clinical characteristics are newly associated with lack of chest pain during heart attack and may help doctors more quickly identify and treat these patients.

See "Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain," by Dr. Canto, Michael G. Shlipak, M.D., M.P.H., William J. Rogers, M.D., and others, in the June 28, 2000, Journal of the American Medical Association 283(24).

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