Chest pain, caused by lack of oxygen to the heart, is considered the cardinal clinical sign of unstable angina pectoris. Yet over half (52 percent) of elderly Medicare patients hospitalized with unstable angina had no chest pain in a recent study. Instead, they suffered from nausea, labored breathing, arm pain, and other atypical signs of unstable angina and were treated less aggressively than patients with usual symptoms.
Fortunately, there was no difference in the number of deaths between patients with unstable angina who had typical or atypical symptoms. Nevertheless, national educational initiatives should probably redefine the classic presentation of unstable angina to include atypical presentations to ensure appropriate quality of care, according to a recent study that was supported by the Agency for Healthcare Research and Quality (HS08843).
John G. Canto, M.D., M.S.P.H., and Catarina I. Kiefe, M.D., Ph.D., of the University of Alabama at Birmingham, and their colleagues examined the medical records of 4,167 randomly selected Medicare patients hospitalized with unstable angina at 22 Alabama hospitals between 1992 and 1999. They defined a typical unstable angina presentation as chest pain located substernally in the left or right chest or chest pain characterized as squeezing, tightness, aching, crushing, arm discomfort, dullness, fullness, heaviness, pressure, or pain aggravated by exercise or relieved with rest or nitroglycerin.
Among patients with confirmed unstable angina, 52 percent had atypical presentations. The most frequent atypical symptoms were shortness of breath (69 percent), nausea (38 percent), profuse sweating (25 percent), fainting (11 percent), or pain in the arms (12 percent), upper middle abdomen (8 percent), shoulder (7 percent), or neck (6 percent). Patients with atypical symptoms received aspirin, heparin, and beta-blocker therapy less aggressively, but this did not result in increased mortality. Patients more likely to have atypical symptoms were older, female, suffering from dementia, had no history of heart attack or high cholesterol, and had no family history of heart disease.
See "Atypical presentations among Medicare beneficiaries with unstable angina pectoris," by Dr. Canto, M.D., Contessa Fincher, Ph.D., M.P.H., Dr. Kiefe, and others, in the August 1, 2002, American Journal of Cardiology 90, pp. 248-253.
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