Recognition of Atypical Symptoms of Acute Myocardial Infarction: Development and Validation of a Risk Scoring System

Recognition of Early Cardiovascular Disease Symptoms in Hypertensive and Dyslipidemic Individuals of Icheon, Korea: Insights into Educational Levels and Health Literacy

The study aimed to explore the relationship between the presence of hypertension or dyslipidemia and the recognition of early symptoms of cardiovascular diseases (CVD), particularly acute myocardial infarction (AMI) and stroke. It is crucial for individuals with hypertension or dyslipidemia to recognize early symptoms of AMI and stroke, as timely and appropriate intervention can lead to favorable health outcomes. The study enrolled 104 participants aged 19 and above who are current residents of the Icheon region, Gyeonggi, Korea. The assessment of early symptoms of AMI and stroke utilized adapted items from the Korea Community Health Survey. In consideration of health literacy and education attainment, logistic regression analyses were conducted. While there was no significant association between hypertension and awareness of AMI or stoke symptoms, individuals with dyslipidemia demonstrated enhanced recognition of specific AMI symptoms, such as 'sudden chest pain or pressure' and 'sudden feeling of breathlessness'. No significant associations were observed between hypertension or dyslipidemia and awareness of stroke symptoms. The study emphasized the significance of targeted health education programs for individuals with chronic conditions to enhance their awareness of early symptoms of AMI and stroke.

Chest pain symptoms during myocardial infarction in patients with and without diabetes: a systematic review and meta-analysis

OBJECTIVE

Chest pain (CP) is key in diagnosing myocardial infarction (MI). Patients with diabetes mellitus (DM) are at increased risk of an MI but may experience less CP, leading to delayed treatment and worse outcomes. We compared the prevalence of CP in those with and without DM who had an MI.

METHODS

The study population was people with MI presenting to healthcare services. The outcome measure was the absence of CP during MI, comparing those with and without DM. Medline and Embase databases were searched to 18 October 2021, identifying 9272 records. After initial independent screening, 87 reports were assessed for eligibility against the inclusion criteria, quality and risk of bias assessment (Strengthening the Reporting of Observational Studies in Epidemiology and Newcastle-Ottawa criteria), leaving 22 studies. The meta-analysis followed Meta-analysis Of Observational Studies in Epidemiology criteria and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled ORs, weights and 95% CIs were calculated using a random-effects model.

RESULTS

This meta-analysis included 232 519 participants from 22 studies and showed an increased likelihood of no CP during an MI for those with DM, compared with those without. This was 43% higher in patients with DM in the cohort and cross-sectional studies (OR: 1.43; 95% CI: 1.26 to 1.62), and 44% higher in case-control studies (OR: 1.44; 95% CI: 1.11 to 1.87).

CONCLUSION

In patients with an MI, patients with DM are less likely than those without to have presentations with CP recorded. Clinicians should consider an MI diagnosis when patients with DM present with atypical symptoms and treatment protocols should reflect this, alongside an increased patient awareness on this issue.

PROSPERO REGISTRATION NUMBER

CRD42017058223.

"I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction

OBJECTIVES

Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers.

METHODS

Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied.

RESULTS

Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see".

CONCLUSION

Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response.

PRACTICE IMPLICATIONS

Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

Myocardial Infarction Signs and Symptoms: Females vs. Males

Cardiovascular disease is the number one killer of females in the United States today, and myocardial infarction (MI) plays a role in many of these deaths. Females also present with more "atypical" symptoms than males and appear to have differences in pathophysiology underlying their MIs. Despite both differences in symptomology and pathophysiology being present in females versus males, a possible link between the two has not been studied extensively. In this systematic review, we analyzed studies examining differences in symptoms and pathophysiology of MI in females and males and evaluated possible links between the two. A search was performed for sex differences in MI in the databases PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Biomedical Reference Collection: Comprehensive, Jisc Library Hub Discover, and Web of Science. Seventy-four articles were ultimately included in this systematic review. Typical symptoms for both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) such as chest, arm, or jaw pain were more common in both sexes, but females presented on average with more atypical symptoms such as nausea, vomiting, and shortness of breath. Females with MI also presented with more prodromal symptoms such as fatigue in days leading up to MI, had longer delays in presentation to the hospital after symptom onset, and were older with more comorbidities than males. Males on the other hand were more likely to have a silent or unrecognized MI, which concurs with their overall higher rate of MI. As they age, females have a decrease in antioxidative metabolites and worsened cardiac autonomic function than male. In addition, at all ages, females have less atherosclerotic burden than mles, have higher rates of MI not related to plaque rupture or erosion, and have increased microvasculature resistance when they have an MI. It has been proposed that this physiological difference is etiologic for the male-female difference in symptoms, but this has not been studied directly and is a promising area of future research. It is also possible that differences in pain tolerance between males and females may play a role in differing symptom recognition, but this has only been studied one time where females with higher pain thresholds were more likely to have unrecognized MI. Again, this is a promising area for future study for the early detection of MI. Finally, differences in symptoms for patients with different atherosclerotic burden and for patients with MI due to a cause other than plaque rupture or erosion has not been studied and are both promising avenues to improve detection and patient care in the future.

Missed acute myocardial infarction: an underrecognized problem that contributes to poor patient outcomes

Ischemic heart disease is the number one killer in the world. While improvements in the management of acute myocardial infarction (AMI) have resulted in lower mortality rates, there are still cases where AMI is missed with rates varying depending on the setting where the evaluation took place, the population sample, the definition of missed AMI and timing of evaluation. There is consistent evidence that missed AMI is associated with increased risk of complications and mortality. Many factors contribute to missed AMI which include patient factors, clinician factors and institutional factors. While several studies have been conducted to evaluate missed AMI, there is considerable heterogeneity in methodology, which has resulted in variable rates of missed AMI and the factors associated with missed AMI. In this review, we provide an overview on missed AMI discussing rates reported in the literature, why it is important, reasons why it occurs, some of the challenges in evaluating missed AMI and what could potentially be done to reduce these undesirable outcomes for patients.

Sensation of laryngeal obstruction as a manifestation of myocardial infarction: A case report

A rare case of a 62-year-old woman with an atypical cardiac symptom of sensation of laryngeal obstruction as a manifestation of acute coronary syndrome is described. Initially, the patient showed unremarkable test results and was diagnosed with laryngopharyngitis and discharged from hospital. However, 24 hours later she returned to the hospital with an abnormal electrocardiogram (ECG) and elevated blood troponin levels and was diagnosed with ST-segment elevation myocardial infarction (STEMI). She developed heart failure, cardiogenic shock and died. Clinicians should be aware that patients with an unexplained sensation of laryngeal obstruction should be considered for the presence of MI within their differential diagnosis since this may be the only symptom in some patients with life-threatening cardiac ischemia.

The receptive field for visceral pain referred orofacially by the vagus nerves

BACKGROUND

The nociceptive receptive field of the vagus nerves in animals includes virtually the entire thoracic, abdominal and laryngopharyngeal regions. However, the role of the vagus nerves in the transmission of visceral pain in humans, with the exception of pain from coronary artery diseases, is believed to be insignificant.

AIM

The purpose of this report is to map out the clinical visceral pain receptive field of the vagus nerves relative to its nociceptive counterpart in animals.

MATERIALS AND METHODS

The PubMed database and PMC were searched for case reports of patients with orofacial pain believed by the author(s) of the article to be referred from underlying non-cardiac thoracic, laryngopharyngeal or abdominal diseases. Reports of diseases for which non-neural explanations for the orofacial spread of pain were suggested were excluded.

RESULTS

A total of 52 case reports of jaw pain and/or otalgia referred from laryngopharyngeal and noncardiac thoracic sources were discovered. In addition, a multicenter prospective study found that 25.8% of more than 3,000 patients with thoracic aortic dissection experienced pain in the head and neck region. In stark contrast, no case reports of orofacially referred pain from abdominal diseases were found.

DISCUSSION

The results indicate that the laryngopharyngeal and thoracic portions of the vagal receptive field are capable of referring pain orofacially while the abdominal portion is not. The roles of the somatotopic organization of the trigeminal sub nucleus caudalis and neuromodulation in this referral of pain were discussed.

CONCLUSION

Referred orofacial pain can lead to delayed diagnosis and poorer outcome in visceral diseases.

Low level of knowledge of heart attack symptoms and inappropriate anticipated treatment-seeking behaviour among older Chinese: a cross-sectional survey

BACKGROUND

Prehospital delay of acute myocardial infarction (AMI) is common globally, and Hong Kong-home of a rapidly ageing Chinese population-is not an exception. Seeking emergency medical care promptly is important for patients. Treatment-seeking behaviours have been shown to be associated with knowledge of AMI symptoms and specific cultural beliefs. This study aimed to assess the level of knowledge of AMI symptoms and expected treatment-seeking behaviour among older Chinese in Hong Kong.

METHODS

A cross-sectional population-based survey was conducted at the Elderly Health Centres in Hong Kong from March to September 2016. Face-to-face interviews were conducted with a structured questionnaire based on previous studies and local adaptations.

RESULTS

Among 1804 people aged 65 years and above who completed the questionnaire, chest pain (80.2%), palpitations (75.8%) and fainting (71.9%) were the major symptoms recognised as AMI related. Meanwhile, stomach ache (46.9%), coughing (45.4%) and neck pain (40.8%) were recognised as not AMI related. The mean expected discomfort intensity during AMI onset was 7.7 out of 10 (SD=2.1). Regarding the expected treatment-seeking behaviour, seeking non-emergent medical care was the most popular action when AMI symptoms emerged during the day, without chest pain or with lower discomfort intensity, whereas calling an ambulance was the most common option when AMI symptoms emerged at night or with high discomfort intensity.

CONCLUSIONS

To minimise delays in seeking treatment, future health education should focus on increasing the public knowledge of AMI symptoms and the need to call an ambulance during an emergency.

[Knowledge of the population about leading symptoms of cardiovascular emergencies and the responsibility and accessibility of medical facilities in emergencies : Results of the KZEN study in Western Palatinate]

BACKGROUND

The Westpfalz is a mainly rural region in the southwestern part of the German state of Rhineland-Palatinate with 527,000 inhabitants and demonstrates a higher than average cardiovascular mortality compared to the rest of Germany. The reasons are not known. Our study attempted to investigate whether significant deficits in knowledge of the population on cardiovascular emergencies, the accessibility of emergency medical services (EMS) or the different responsibilities and abilities of the medical facilities could be held responsible for this. These factors are of the utmost importance for the timely initiation and administration of curative therapeutic strategies.

METHODS

We conducted standardized telephone interviews with 1126 inhabitants of Westpfalz as a representative sample of the population in the study area. The interviewees were asked about demographic data, participation in first aid courses, knowledge of emergency telephone numbers and the different responsibilities of preclinical emergency physicians which are a part of the EMS and the doctor-on-call system for non-life-threatening conditions (ÄBD). Moreover, we asked about the leading symptoms of myocardial infarction and stroke. Finally, we enquired how the respondents would react in fictitious cardiovascular emergencies.

RESULTS

Of the participants 651 (57.8%) were female and 475 (42.2%) male. The mean age in our study was 51 ± 18 years and 1002 of the participants (89%) had some formal first aid training. The current telephone number of the EMS system (112) was known to 29.5% of the interviewees and 15.4% could only recall the old number (19222) which is no longer in use. In the case of participants who gave the correct telephone number the first aid course took place 10 years ago (median), whereas for participants who did not know the correct number, the course dated back 15 years (median, p < 0.01). The telephone number 116117 of the ÄBD, usually a family physician, was familiar to only 23 of the people interviewed (2.0%). The basic differences in the functions and responsibilities of the ÄBD and the emergency physician within the EMS were known to only 235 participants (20.2%), 231 (20.5%) were not able to name a single leading symptom of a myocardial infarction and 354 did not know a leading symptom (31.4%) of stroke. In the fictitious case report of an unconscious patient with respiratory arrest (as a sign of cardiac arrest) 96.8% of the interviewees would have correctly informed the EMS, for patients with acute coronary syndrome 81.8% and for a stroke patient 76.8% (cardiac arrest vs. acute coronary syndrome: p < 0.001, cardiac arrest vs. stroke: p < 0.001, acute coronary syndrome vs. stroke: p = 0.005).

CONCLUSION AND RECOMMENDATIONS

A large proportion of the population were found to be ignorant about the telephone numbers for medical emergency calls and the different functions of the ÄBD and emergency physicians within the EMS. Moreover, our results indicate that a significant percentage of the population would neither be in a position to recognize a stroke or myocardial infarction in an emergency situation nor be informed enough to communicate with the correct part of the emergency system. The association of these deficits with the time elapsed since the last first aid course should be reason enough to continuously motivate the population, especially at risk patients and their relatives, to repeat such courses several times. Furthermore, digital media should be used more intensively in providing first aid instructions. In our opinion, this study clearly shows that in Germany a uniform number for medical emergency calls is mandatory.

Predictors of pre-hospital delay in Hong Kong Chinese patients with acute myocardial infarction

BACKGROUND

The pre-hospital delay to seek care remains the most significant barrier for effective management of acute myocardial infarction. Many of the previous studies mainly took place in Western countries. Few data are available about the care-seeking behavior of Hong Kong Chinese.

AIM

The purpose of this study was to identify the predictors of pre-hospital delay in care seeking among Hong Kong Chinese patients with acute myocardial infarction.

METHODS

Adult Chinese patients ( n=301) with a confirmed diagnosis of acute myocardial infarction were recruited from the cardiac units of three regional hospitals in Hong Kong. Various socio-demographic, clinical, symptom presentation characteristics and patient perceptual factors were considered as potential predictors. Multivariate analysis was conducted to identify the independent predictors with pre-hospital delay in care-seeking among acute myocardial infarction patients.

RESULTS

Perceived barriers to care seeking constituted the most significant predictor for longer pre-hospital delay in acute myocardial infarction patients. Female gender was also significant in predicting longer delay, whereas a greater extent of symptom congruence and a greater extent of typical symptom presentation were significantly associated with a shorter delay. The final model accounted for 49.6% of the variance in pre-hospital delay as a whole.

CONCLUSION

The most prominent predictors of pre-hospital delay are modifiable in nature, including the perceived barriers to care seeking and symptom congruence. Other sociodemographic and clinical factors also influence patients' decision. Although these are non-modifiable, our findings provide important insight for educating high-risk individuals.

Promoter Polymorphism (-174, G/C) of Interleukin-6 and Arterial Thromboembolic Events: A Meta-Analysis

Background

Ischemic stroke and myocardial infarction are fatal diseases and are among the top 10 causes of death in Korea, including arterial thromboembolic events. Many previous studies have described the function of interleukin-6 (IL-6) in arterial thromboembolic events and the association between promoter single-nucleotide polymorphism (SNP) (rs1800795; −174, G/C) of the IL-6 gene. However, these results were controversial. Therefore, we performed a meta-analysis to more precisely assess the association between the SNP of the IL-6 gene and susceptibility to arterial thromboembolic events.

Material/Methods

We used PubMed, Embase, Google Scholar, and Korean Studies Information Service System (KISS) electronic databases. Comprehensive Meta-analysis software (Corporation, NJ) was used to evaluate the relationship between rs1800795 SNP of IL-6 gene and risk of arterial thromboembolic events. Odds ratio (OR), 95% confidence interval (CI), and P value were also calculated. The 13 eligible studies were analyzed in the meta-analysis.

Results

The present meta-analysis found that rs1800795 SNP of IL-6 gene is not significantly associated with susceptibility to arterial thromboembolic events (C allele vs. G allele, OR=1.04, 95% CI=0.91–1.19, P=0.619; CC vs. CG+GG, OR=1.09, 95% CI=0.91–1.31, P=0.364; CC+CG vs. GG, OR=0.97, 95% CI=0.78–1.21, P=0.763, respectively), and the SNP of IL-6 gene also did not show any significant association with ischemic stroke or myocardial infarction (P>0.05 in each model).

Conclusions

We found that rs1800795 SNP of IL-6 gene was not related to arterial thromboembolic events. However, further study will be needed to confirm these results.