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Clinical Decisionmaking

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Absence of chest pain in patients with suspected heart attack or angina does not signal a less severe condition

Not all patients with acute coronary syndrome (ACS), such as heart attack or angina, suffer from chest pain. The absence of chest pain in such patients does not necessarily signal a less severe condition, warn the authors of a recent study. They found that patients with suspected ACS who arrived at the hospital emergency department (ED) with no chest pain were more likely to die in the hospital than those who had chest pain.

Patients with painless ACS tended to be older, were more often women, and more often had diabetes and prior heart attacks. It may be that prior heart damage impairs pain perception due to disruption of sensory receptors, and that diabetes impairs pain perception, suggests Harry P. Selker, M.D., M.S.P.H., of the Tufts-New England Medical Center.

Dr. Selker and his colleagues studied the impact of lack of chest pain on triage and outcomes of 10,793 patients with symptoms suggestive of ACS who presented at the EDs of 10 California hospitals. A final diagnosis of ACS was confirmed in 24 percent of patients; 35 percent of these patients had a heart attack and 65 percent unstable angina pectoris. Pain was absent in 6.2 percent of patients with acute ischemia and 9.8 percent of heart attack patients.

Among ACS patients overall, there were no differences in ED triage between patients who did and did not have pain. However, significantly fewer heart attack patients without pain were admitted to a critical care unit than similar patients with pain (51 vs. 67 percent). After controlling for clinical features, lack of pain during acute ischemia predicted increased hospital mortality. Further investigation is needed to uncover the reasons for this increased mortality, concludes Dr. Selker.

See "Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: A multicenter study," by Boris E. Coronado, M.D., J. Hector Pope, M.D., John L. Griffith, Ph.D., and others in the November 2004 American Journal of Emergency Medicine 22(7), pp. 568-574.

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