It felt as if a 10-ton truck had
driven into him, but new research shows that the crushing
chest pain may have saved Bernie Laurier's life. The
56-year-old airline pilot's moaning and groaning in
the emergency room made it easy for the overworked physician
to diagnose a heart attack. A study in August issue
of Chest shows that Bernie's situation is not
unique. Heart attack patients are three times more likely
to die if they experience a painless heart attack than
if they suffer the typical excruciating heart attack
— mostly because of errors and delays in diagnosis
and treatment.
Investigators reviewed 20,881 cases
of patients admitted to hospital due to various acute
coronary syndromes between 1999 and 2002. This database,
known as the Global Registry of Acute Coronary Events
(GRACE), is drawn from 14 developed countries, including
Canada, the US, Britain, France and Australia.
Lead author Dr David Brieger from
Concord Hospital in Sydney, Australia, stresses that
painless heart attacks are not necessarily symptomless.
"While the majority of people who have acute coronary
syndromes, such as heart attacks and unstable angina,
feel chest pain, some do not but instead may experience
atypical symptoms of fainting, shortness of breath,
excessive sweating or nausea and vomiting. Other than
excessive sweating, each of the dominant symptoms of
a heart attack not accompanied by chest pain independently
identifies a population that is at increased risk of
dying."
The individuals that make up this
population were more likely to be older women with a
history of diabetes, heart failure or hypertension.
However, only 1,763 of the 20,881 patients surveyed
reported no pain.
It's what happened to those 1,763
that's alarming. No fewer than 13% of them died in hospital,
compared to just 4.3% of the patients who did report
pain. Moreover, a dismal 23.8% of these patients were
misdiagnosed upon their arrival at hospital, compared
to just 2.4% of those who were in agony. In fact, while
65.5% of patients with pain received beta-blockers in
the first 24 hours, only 54.5% of patients without pain
did.
The pattern is clear enough. Doctors
know that heart attacks are generally accompanied by
pain, therefore when they see a pain-free patient they
fail to consider a diagnosis of heart attack. "We hope
that our findings will remind physicians that these
events do occur in the absence of chest pain and will
prompt them to make the diagnosis and institute the
appropriate treatment more rapidly," said Dr Brieger.
But it's not just a question of
treatment delayed, according to Dr Brieger. Upon discharge,
pain-free patients were still being short-changed —
only 45.9% were sent home with statins, compared to
52.2% of those who reported pain.
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