Seventy-six percent of non-ST-elevation myocardial infarction (NSTEMI) patients with dyspnea or fatigue as the main presenting symptom survived at one year compared to 94% patients with chest pain as the main symptoms, according to findings presented at the recently concluded European Society of Cardiology (ESC) Acute CardioVascular Care 2022 virtual Congress.1

For this retrospective study, researchers analysed data of 4726 adults hospitalized with non-ST-elevation myocardial infarction (NSTEMI) between October 2010 and September 2019 obtained from the Portuguese Registry of Acute Coronary Syndromes. Seventy-one percent of the study subjects were male and the average age of the participants was 68 years.

Based on the major presenting symptom, three categories of patients were formed. Majority of patients (91%) presented with chest pain, while 7% presented with dyspnea and fatigue as the main symptoms and just 2% had syncope. All-cause mortality at one year after the acute event was the primary outcome measure, while hospitalization due to cardiovascular cause at one year was the secondary outcome endpoint.

The average age of patients who presented with fatigue or dyspnea was 75 years vs 74 years in patients with syncope and 68 years in those with chest pain. Women presented less commonly with chest pain (29%); their most common presenting symptom was fatigue or dyspnea (42%) followed by syncope (37%). The probability of underlying medical conditions such as hypertension, diabetes, chronic kidney disease and chronic obstructive pulmonary disease (COPD) was higher in patients who had fatigue or dyspnea when compared with those who had chest pain or syncope as the major presenting symptoms.

The one-year survival rate was 94% in patients with chest pain and 92% in patients with syncope. However, patients with dyspnea or fatigue had a survival rate of just 76% at one year. When re-hospitalization rates due to cardiovascular causes were compared between the three groups of patients, those with dyspnea or fatigue had the highest rehospitalization rate (24%) vs 17% in patients with syncope vs 15% in those with chest pain. On multivariate analysis, neither symptom was found to be predictive of survival at one year after adjusting for age, atrial fibrillation, left ventricular ejection fraction, major bleeding, ventricular tachycardia and COPD.

These findings show that NSTEMI patients with dyspnea or fatigue as presenting symptoms fared worse compared to patients with chest pain, with lower one year survival and higher rehospitalization rates within one year of the acute cardiovascular event.

While chest pain is the classical symptom of a myocardial infarction, this study highlights the atypical presentation of NSTEMI. A high index of suspicion for an acute coronary event is required in patients, particularly women, older adults and those with comorbid conditions, presenting with symptoms other than chest pain such as dyspnea or fatigue. Patients should be educated to be alert to these atypical symptoms such as dyspnea and seek urgent medical attention as it could be a sign of a heart attack. Pain is a better blessing than absence of it, since it alerts on time. In infarct, time is muscle. Timely intervention ensures better short- and long-term survival. Any delay in diagnosis and management could result in worse patient outcomes.

Reference

1. Medeiros P, et al. Abstract 20248. Symptoms at NSTEMI presentation - do they predict the outcome? ESC Acute CardioVascular Care Congress 2022; March 18-19, 2022. https://www.escardio.org/The-ESC/Press-Office/Press-releases/Shortness-of-breath-heralds-worse-survival-than-chest-pain-for-heart-attack-patients.