Chest
Clinical InvestigationsCARDIOLOGYAcute Coronary Syndromes Without Chest Pain, An Underdiagnosed and Undertreated High-Risk Group: Insights From The Global Registry of Acute Coronary Events
Section snippets
Materials and Methods
The full details of the GRACE rationale and methodology have been published.1011 GRACE is designed to reflect an unbiased population of patients with ACSs, irrespective of geographic region. Currently, 95 hospitals located in 14 countries (ie, Argentina, Australia, Austria, Belgium, Brazil, Canada, France, Germany, Italy, New Zealand, Poland, Spain, the United Kingdom, and the United States) are participating in this observational study.
Patients enrolled in the registry had to be at least 18
Frequency of Atypical Symptoms
Over the period July 1999 to June 2002, 20,881 patients were admitted to the hospital with ACSs, of whom 1,763 (8.4%) presented with atypical symptoms. The dominant presenting symptoms in these patients were dyspnea in 869 (49.3%), diaphoresis in 462 (26.2%), nausea or vomiting in 426 (24.3%), and presyncope/syncope in 335 (19.1%) [Fig 1].
Patient Characteristics
Patients without chest pain were significantly older than those with typical symptoms. They were more likely to be women and to have a history of
Discussion
Although presentations with ACSs share common underlying pathophysiologic mechanisms, they offer a challenge from the standpoint of diagnosis, treatment, and prognosis because the clinical manifestations of these conditions vary considerably. Most episodes of ACSs are characterized predominantly by chest pain. However, a proportion of patients may have atypical, minimal, or no symptoms.
In our population, patients with atypical symptoms were more likely to be older, female, hypertensive, and
Conclusions
This analysis has shown that patients with acute coronary ischemia in the absence of chest pain are older and sicker than those with chest pain. The diagnosis is often made belatedly, and initial and subsequent hospital management is suboptimal. With the exception of diaphoresis, each dominant presenting symptom independently identifies a population that is at increased risk of dying. These patients represent a high-risk group, independent of whether their presentation is accompanied by
GRACE Co-Chairs
Keith A. Fox, The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK; and Joel M. Gore, University of Massachusetts Medical School, Worcester, MA.
GRACE Publication Committee Co-Chairs
Kim A. Eagle, University Hospital, Ann Arbor, MI; and P. Gabriel Steg, Hôpital Bichat, Paris, France.
Committee Members
Giancarlo Agnelli, University of Perugia, Perugia, Italy; Frederick A. Anderson Jr, University of Massachusetts Medical School, Worcester, MA; Álvaro Avezum, CTI-A Hospital Albert Einstein, São Paulo, Brazil; David Brieger, Concord Hospital, Sydney,
ACKNOWLEDGMENT
The authors of this report would like to express their gratitude to the physicians and nurses participating in GRACE. Further information about GRACE, along with a complete list of participants, is available at www.outcomes.org/grace.
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GRACE is supported by an unrestricted educational grant from Aventis Pharma, Bridgewater, NJ.
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A complete list of investigators and institutions can be found in the Appendix.