OBJECTIVES:
It is well recognized that cardiac autonomic neuropathy associated with diabetes mellitus (DM) can cause silent myocardial ischemia, however there is limited research examining how the cardiac symptoms reported by patients with DM presenting with acute coronary syndromes (ACS) can affect the immediate and long term outcomes. The aim of the current study was to examine the prognostic impact of lack of chest pain symptoms in DM patients presenting with ACS and enrolled in a multicenter multinational ACS registry from the Middle East.
METHODS:
For a period of 9 months in 2008 to 2009, 7,930 consecutive patients with ACS were enrolled from 65 hospitals in 6 Middle East countries. A cohort of 3135 patients with DM were selected of whom 2686 (85.7%) presented with chest pain while 449 patients (14.3%) had no chest pain. Clinical features and outcomes were examined and compared among the two groups.
RESULTS:
Diabetic patients without chest pain were 5 years older and had significantly higher rates of hypertension (76.1% vs. 63.2%), prior myocardial infarction (35.9% vs. 24.3%), chronic kidney disease (CKD) (17.1% vs. 5.9%) and had significantly higher GRACE risk scores (55.3% vs. 21.4%) at presentation compared to patients with chest pain [All P <0.001]. Covariates independently associated with lack of chest pain in DM patients were; higher Killip class on presentation (OR, 6.2 [95%CI, 4.80-7.88]), female gender (OR, 1.50 [95%CI, 1.14-1.96]), CKD (OR, 1.8 [95%CI, 1.27-2.61]), tachycardia (OR, 2.50 [95%CI, 1.94-3.19]) and advanced age (OR, 1.03 [95%CI, 1.02-1.04]), [All P =0.001]. DM patients without chest pain had a significantly higher in-hospital and 1-year mortality rates (11.4% vs. 3.8%, P =0.001, and 25.7% vs. 12.2%, P =0.001, respectively). Lack of chest pain was an independent predictor of in-hospital and one year mortality (OR, 3.05 [95%CI, 2.05-4.54], P =0.001, and OR, 2.0 [95%CI, 1.52-2.75], P =0.001, respectively).
CONCLUSIONS:
DM patients with ACS presenting without chest pain are at an increased risk of immediate and long term mortality. Understanding the factors associated with atypical presentations of ACS in patients with DM may help in the earlier detection and more appropriate management of these high risk patients.
Potential value for new diagnostic markers in the early recognition of acute coronary syndromes