Chest-pain-free heart attacks more deadly
One in 12 heart attack victims has atypical symptoms and is more likely to be misdiagnosed or improperly treated, a new study has found

By André Picard
Public Health Reporter
Tuesday, August 10, 2004

There is a history of heart attacks in Joyce Singer's family, so she was acutely aware of the telltale symptom, "a bone-crushing chest pain that has you falling to your knees and grabbing at your chest."

But, in her case, the Hollywood version of a heart attack never came. Rather, Ms. Singer suffered a whole series of aches and pains, including indigestion, shoulder pain and shortness of breath that she dismissed as symptoms of working too hard.

When she finally got around to seeing her family doctor, he realized right away that the Toronto real estate agent had indeed had a heart attack -- and probably several -- without once experiencing the typical chest pain. Within days, she underwent a quadruple bypass.

New research, published in today's edition of the medical journal Chest, reveals that about one in every 12 people who suffer heart attacks has atypical symptoms.

Instead of the stereotypical "elephant on the chest," they suffer more mundane signs, such as shortness of breath, excessive sweating, fainting, nausea and vomiting, and nagging pains in the shoulder or jaw.

The study, conducted by an international team that included researchers at St. Michael's Hospital in Toronto, found that those suffering atypical heart attack symptoms tend to be women, seniors over the age of 65 and people with chronic conditions such as diabetes.

The absence of chest pain has severe consequences: These patients are far less likely to get prompt treatment, or to benefit from the full range of treatments.

Heart attack sufferers with atypical symptoms are also 10 times more likely to be misdiagnosed, and three times more likely to die than those who suffer chest pain.

David Brieger, a cardiologist at Concord Hospital in Sydney, Australia, and the lead researcher on the study, said that the findings should serve notice to doctors that diagnosing a heart attack is not always straightforward and they need to be alert and open-minded.

"Often, when a patient arrives at the hospital without chest pain, it is only after blood test results come back or other diagnoses are excluded that the physician reassesses the situation and realizes it is an acute cardiac event after all," he said.

"We hope 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."

A heart attack occurs when a coronary artery (which supplies oxygen and nutrients to the heart muscle) becomes blocked by a buildup of fatty plaque.

To conduct the study, researchers analyzed data from 20,881 patients in 14 countries who were hospitalized with a variety of health conditions between July, 1999, and June, 2002.

Of the 1,763 patients who had heart attacks without experiencing chest pain, 13 per cent died in hospital, compared to 4.3 per cent of those with chest pain.

Almost 24 per cent of patients without chest pain were misdiagnosed when they arrived at the hospital, compared to only 2.4 per cent who had typical symptoms. Patients with atypical symptoms were also less likely to be treated with anticoagulants (blood thinners) and to undergo bypass surgery and angioplasty (using a small, inflatable balloon to clear a blockage).

Beth Abramson, a cardiologist and spokeswoman for the Heart and Stroke Foundation of Canada, said the "study should serve as an important tool to educate physicians."

But, just as important, it should serve as a reminder to members of the public at large that they should seek immediate medical attention when they have unusual symptoms, such as fainting, numbness, persistent fatigue and unusual vomiting.

"Again and again, I see patients who have bad outcomes because they didn't seek prompt medical attention. You have to remember that time is heart muscle," Dr. Abramson said.

She also stressed that, while it is important to be aware of atypical symptoms, the research shows that 92 per cent of heart attacks involve chest pain, so "that is a really important sign of a heart attack that you should not ignore."

Almost 80,000 Canadians annually die of heart disease, according to the Heart and Stroke Foundation of Canada.

Heart attack signs

Sudden discomfort or pain that does not go away with rest.

Pain that may be in the chest, neck, jaw, shoulder or arms.

Back pain that may feel like burning, squeezing, heaviness, tightness or pressure.

In women, pain may be more vague.

Shortness of breath.

Difficulty breathing.

Nausea, indigestion, vomiting.

Sweating.

Cool, clammy skin.

Fear, anxiety, denial.

Signs may be mild or severe.

Source: the Heart and Stroke Foundation of Canada