Modes of Presentation of Acute Myocardial Infarction: Original Article
Modes of Presentation of Acute Myocardial Infarction: Original Article
Modes of Presentation of Acute Myocardial Infarction: Original Article
Original Article
Aim: To study the various modes of presentation of acute myocardial infarction (AMI). Methods: A total
number of 60 patients of AMI admitted in various teaching hospitals of Kasturba Medical College, Mangalore,
were studied. The following factors were evaluated: onset of symptoms, mode of presentation, site of
infarction, and hospital outcome. Results: Out of 60 patients, 12 (20%) presented with atypical symptoms.
The maximum incidence AMI with atypical symptoms was in the age group of 65–74 yr (30.7 %), followed
by the age group of 55–64 yr (25%). No patient presented with atypical symptoms below 30 yr. Patients
experiencing MI without chest pain tended to be older (mean age 61 vs 58 yr) and were women (35% vs
12.5%); 80% of patients presented with chest pain followed by dyspnea (28.3%) and vomiting (13.3%). The
in-hospital mortality of MI patients who presented with typical and atypical symptoms were 16.6% and
33.3%, respectively. In this study, anteroseptal infarction was most common (31.6%). Fifty percent of infe
rior-wall MI patients presented with atypical symptoms. Conclusion: In this study, there was no significant
association between onset of MI and circadian pattern.
From:
Identifying the symptoms and signs of acute AMI is
Department of Medicine, Kasturba Medical College, Mangalore paramount for successful management and early treat
*Department of Pharmacology, Kasturba Medical College, Mangalore
ment. Patients must realize that their symptoms may be
Correspondence:
consistent with cardiac disease and numerous reports
Dr. Nithyananda Chowta K, Department of Medicine, Kasturba Medical
College Hospital, Attavar, Mangalore-575001. E-mail: knchowta@yahoo.com have shown that patients may delay seeking care if they
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do not know that their symptoms may be consistent with Table 3 shows the presenting symptoms of AMI. Eighty
MI. The problem is further compounded if patients be percent of patients presented with chest pain, followed
lieve that chest pain is a necessary hallmark feature of by dyspnea (28.3%), sweating (21.7%), and vomiting
acute MI.[7–9] (13.3%). Epigastric pain was the presenting symptom in
10% of patients. Three patients gave history of syncopal
In the studies confined to the local population, work attack as the presenting symptom. Three patients com
done on the modes of presentation of AMI was insuffi plained palpitation. Only one patient with atypical symp
cient. The present study has been undertaken to evalu tom had previous history of angina (8.33%) compared
ate various modes of presentation in patients with AMI with patients with typical symptoms with history of an
and finds out whether there is a circadian pattern in the gina (20.83%). The in-hospital mortality of MI patients
onset of AMI. who presented with typical and atypical symptoms were
16.6% and 33.3%, respectively (Table 4). The
Materials and Methods anteroseptal infarction was most common (31.6%) and
Patients with AMI admitted in various teaching hospi mortality was high in anterior-wall MI. Among the infe
tals of Kasturba Medical College, Mangalore, were stud rior-wall MI patients 50% presented with atypical symp
ied. The diagnosis was confirmed by electrocardiogram toms (Table 5).
(ECG) changes and/or enzyme abnormalities. A total of
60 cases were studied. Discussion
The criteria of ECG changes are as follows. Chest pain has been reported as the cardinal feature
1. Presence of pathological Q-wave. in patients with AMI. The WHO requires the presence of
2. Presence of hyperacute tall T-wave or inverted chest pain as one of the cornerstone feature for the di
T-wave. agnosis of chest pain.[1]
3. Persistent sinus tachycardia segment elevation of
more than 2.5 mm. Table 2: Presentation according to gender
The following factors were considered: (1) onset of Gender Patients with chest pain Without chest pain
Male 35 (87.5%) 5 (12.5%)
symptoms, (2) modes of presentation, (3) site of infarc Female 13 (65%) 7 (35%)
tion, and (4) hospital outcome.
Table 3: Presenting symptoms of AMI
Results Presenting symptom No. %
Out of 60 patients 40 were males (66.66%) and 20 Chest pain 48 80
Dyspnoea 17 28.3
were females (33.33%). Mean age of the patients was Vomiting 8 13.3
59.5 years. Out of 60 patients, 12 (20%) presented with Syncope 3 5
Sweating 13 21.7
atypical symptoms. The maximum incidence AMI atypi Palpitation 3 5
cal symptoms was in the age group of 65–74 years Epigastric pain 6 10
(30.7%) (Table 1), followed by the age group of 55–64
years (25%). No patient presented with atypical symp Table 4: Mortality in patients with typical and atypical
toms below 30 years. Patients experienced myocardial presentation of MI
infarction MI without chest pain tended to be older (mean No. Mortality %
Atypical MI 12 4 33.3
age 61 vs 58 years) and were women (35% vs 12.5%) Typical MI 48 8 16.6
(Table 2).
Table 5: Mode of presentation and prognosis according
to site of infarction
Table 1: Presentation of AMI according to age
Site of infarction Total no. Atypical Mortality
Age Total no. of infarcts Atypical presentation % of cases presentation
<30 3 0 0 Anterior wall 8 1 (12.5%) 3 (37.5%)
30–44 4 1 25 Lateral wall 1 0 0
45–54 10 0 0 Inferior wall 14 7 (50%) 4 (28.6%)
55–64 24 6 25 Ant + Lat 10 2 (20%) 2 (20%)
65–74 13 4 30.7 Ant + Inf + Lat 4 1 (25%) 1 (25%)
>75 6 1 16.6 Ant+ Inf 4 0 0
2
χ = 3.64, P = 0.303, not significant. Ant+ Septal 19 1 (5.3%) 2 (10.5%)
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IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med July-September 2005 Vol 9 Issue 3
In the present study, approx 20% of patients with AMI difference in the electrocardiographic location of the in
presented without chest pain on initial clinical evalua farct between those with atypical and typical symptoms
tion. Patients experienced AMI without chest pain tended of MI. In the Framingham Study[8] also, the proportion of
to be older (mean age 61 vs 58 years) and were women atypical MI did not appear to vary with electrographic
(35% vs 12.5%). location of the infarct.
In the Reykjavik study,[1] approx 30% of MI patients Patients with atypical MI group showed a higher in
presented with atypical symptoms. Results from other hospital mortality than did the typical MI group (33% vs
population studies have shown that 20–60% of all MI 16%), though statistically insignificant. When only the
are presented with atypical symptoms. According to age at MI, the most important determinant of mortality,
Canto and Shlipak,[2] patients presented with atypical was adjusted, the atypical MI had approx 16% higher
symptoms were older and were women. In the present mortality from all causes. In the Framinham study[8] also,
study, there is a slight increase in the incidence of pain age adjusted long-term mortality for all cases were
less infarction with increasing age. In the group between slightly worse among unrecognized MI case than among
55 and 64 years, 25% patients presented with atypical recognized MIs. This is in contrast with the Reykjavik
symptoms and 31% in 65–74 years age group. This is study,[1] in which the prognosis for the patients with atypi
comparable with Kennel[3] and others, where the values cal MI is no better than that for patients with unrecog
were 27% and 31%, respectively. In contrast to earlier nized MI.
studies in which patients who were 70 years or older
were more likely to present without chest pain, in this To conclude, only a comparative small number of pa
study only one patient out of six presented with atypical tients had atypical presentation. Although there was a
symptoms. notable difference regarding age and sex, it was statis
tically insignificant because of the limited sample popu
An increase in the proportion of atypical MI with ad
lation. Patients with inferior-wall MI presented more of
vancing age was not statistically significant although it
ten with atypical symptoms. Mortality was higher in atypi
is not commonly seen before the age of 55. A much
cal group, though statistically insignificant.
larger sample would be required to prove or disprove
the possibility. We have documented a pronounced gen
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