Dr. Arapelly Krishna Simha Reddy, Dr. Satyanarayana Vulchi


Introduction: Chest pain is the most common presentation of acute coronary syndrome presenting to Emergency department. Few patients may present with atypical symptoms and pose a great challenge to the Emergency physicians. Diagnosis has to be made early since maximal mortality occurs within first few hours if treatment is not instituted early. A cross sectional study was conducted in our hospital to study the proportion of atypical symptoms in patients with acute coronary syndrome. Methods: A cross sectional study was conducted in our hospital from August 2016 to September 2017. All patients aged >20 years presenting to Emergency department and fulfilling the following diagnostic criteria were included. The WHO diagnostic criteria were used for diagnosis of Acute coronary Syndrome(9). 1) Clinical history of Ischemic type of chest pain 2) Changes in serial ECG tracings a)ST-segment elevation of more than 1mm in 2 limb leads. b) ST-segment elevation of more than 2 mm in 2 or more contiguous chest leads. c) ST segment depression >0.5mm at J point in >2contiguous leads with positive troponin I. 3) Positive serum cardiac biomarkers (troponin I). The diagnosis was confirmed if 2 out of 3 above components were positive. ECG was done for all patients presenting to ER with symptoms suggestive of acute coronary syndrome. Cardiac enzymes were sent in patients with nonspecific ECG changes. Results: 323 patients were included in our study. Out of which, 269 patients presented with typical chest pain symptoms and 54 (16.71%) patients presented with  atypical chest pain symptoms . The incidence in male and female population was 44.4% and 55.5% respectively. The incidence of atypical symptoms increased with increasing age and was highest in the age group of 71-80 years.

Conclusion: It is crucial to consider acute coronary syndrome as a differential diagnosis in patients with atypical presentation and Emergency physicians should have a knowledge of various atypical presentations. As missed Myocardial infarction has dire consequences, continued efforts are required to reduce incidence, overall mortality and morbidity.


Atypical symptoms; Acute Coronary Syndrome; Atypical MI

Full Text:



Bean WB. Masquerades of myocardial infarction. Lancet 1997;1:1044-46

Canto JG, Shilpak MG, Rogers WJ, Malmgren JA, Fredrick PD, Lambrew CT, Ornato JP, Barron HV, Kiefe CI. Prevelance, Clinical Charecteristics and Mortality among patients with Myocardial Infarction presenting without chest pain. JAMA.2000;283:3223-9

Chowta K N, Prijith P D, Chowta M N. Modes of presentation of acute myocardial infarction. Indian J Crit care Med 2005;9:151-4

Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, Montalescot G. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk:insight from the Global Registry of Acute Coronary Events.Chest.2004;126:461-69

Dorsch MF, Lawrance RA, Sapsford RJ, Durham N, Oldham J, Greenwood DC, Jackson BM, Morrell C, Robinson MB, Hall AS, EMMACE study group. Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain. Heart 2001;86:494-8

ZdZiennicka J, Siudak Z, Zawislak B, Dziewierz A, Rakowski T, Dubiel J, Dudek D. Patients with non-ST elevation Myocardial infarction and without chest pain are treated less aggressively and experience higher in-hospital mortality. Kardiol pol 2007;65:769-75

Herlitz J, Karson BW, Richter A, Strombom U, Hjalmarson A. Prognosis for patients with initially suspected acute myocardial infarction in relation to presence of chest pain, Clin Cardiol 19992;15;570-6

Goldsten RE, Boccuzi SJ, Cruess D. Prognosis after hospitalization for acute myocardial infarction not accompanied by typical ischemic chest pain. The Multicentre Diltiazem Postinfarction Trail Research Group. AM J Med 1995;99:123-31

Gillum Rf, Fortmann Sp, Prineas RJ, Kottke TE. International diagnostic criteria for acute myocardial infarction and acute stroke> Am Heart J. 1984;108:150-58

EI-Menyer A, Zubaid M, Sulaiman K, Almahmeed W, Singh R, Alsheikh-ali A A, Suwandi J, Grace investigators. Atypical presentation of acute coronary syndrome. A significant independent predictor of in-hospital mortality. Journal of cardiology 2011,57:165-71

Jones ID, Slovis CM. Emergency Department evaluation of the chest pain patient. Emerg Med Clin North Am 2001;19:269-82

Grossmaitre P, Vavasseur O, Yachouh E, Courtial Y, Jacob X, Meyran S, Lantelme P. Significance of atypical symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments. Archives of cardiovascular disease 2013;106:586-92

Sukhija R, Dhanwal D, Gambhir DS, Dewan R. Silent myocardial ischemia in patients with type II diabetes mellitus and its relation with autonomic dysfunction. Indian Heart J. 2000:52:540-546

Hwang SY, park EH, Shin ES, Jeong MH. Comparison of factors associated with atypical symptoms in younger and older patients with acute coronary syndromes. J Korean Med SCi.2009;24:789-94

Arenja N, Mueller C, EHL NF, Brinkert M, Roost K, Reichlin T, Sou SM, Hochgruber T,Osswald S, Zellweger MJ. Prevelance, extent and independent predictors of silent myocardial infarction. Am J Med.2013;126:515-22

Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coli cardiol.2006;47:65-71

Droste C, Roskamm H. Pain mechanisms in symptomatic and silent ischemia. Isr J Med Sci.1989;25:487-92

Shakoor M T, Falik S, Shah F. Incidence of atypical presentation of myocardial infarction. Pakistan Heart Journal 2008;41:15-20


  • There are currently no refbacks.