Atypical presentation of acute and chronic coronary artery disease in diabetics

Table 2 Studies which have shown that diabetes mellitus is a predictor of atypical presentation of acute coronary syndrome

Ref.	Study population/	Study type/country	Atypical presentation %	Conclusion
Stern et al[68]	2113 ACS patients	Nationwide survey/Israel	21.7% had no chest pain	In multivariate analysis, variables associated with no anginal pain/atypical symptoms on presentation (ina order): history of heart failure, age, no past angina, diabetes and non-smoking. 18.7% of male patients had no chest pain on presentation vs 29.7% of females
Culić et al[69]	1996 MI patients	A prospective, observational study/Croatia	14.8% had no chest pain	The independent predictors of atypical presentation in both gender; alevels of CK-MB fraction (P < 0.0001 and P = 0.0003, respectively), NIDDM (P = 0.0002 and P = 0.002, respectively), older age (P = 0.001 and P = 0.01, respectively), and no smoking in men (P = 0.005) The independent predictors of the presence of non-pain symptoms; DM (P = 0.048 and P = 0.005, respectively), alevels of CK-MB (P = 0.01 and P = 0.049, respectively) and hypercholesterolemia (P =0.01) in both men and women
Hwang et al[70]	931 newly diagnosed as ACS	Retrospective/ South Korea	7.8% of younger pts and 13.4% of older pts	A logistic regression analysis after adjustment for gender and ACS type indicated that diabetes and hyperlipidemia significantly predicted atypical symptoms in younger patients
MacKenzie et al[71]	64 (12 women with DM)	Descriptive, cross-sectional/Canada	See conclusion	Less chest pain in diabetics vs non-diabetics (P = 0.02) No difference in pain intensity in diabetics with MI vs non-diabetics (P≥ 0.05) Diabetics with UA or MI were more likely to report mid-sternal chest pain (P = 0.04) and chest pain that radiated to the back of the left arm (P = 0.01) than non-diabetics Diabetics with UA or MI reported more SOB (53.1% vs 31.3%; NS) In diabetics with UA or MI, SOB was a factor in deciding to seek care
Coronado et al[72]	2541 (1058 women, 410 women with DM);	Secondary analysis of multisite a prospective clinical trial/United States	6.2% of patients with ACS and in 9.8% of AMI.	DM independent predictor of painless presentation in acute MI, but not in the ACS group. Diabetes more common in non-pain ACS (35% vs 26%; P = 0.01) Shortness of breath most common in the painless presentation group (72%) and women were more likely to have painless ACS (53%) (P = 0.007)
Vaccarino et al[73]	384878 patients	Prospective, observational study/ National Registry of MI/United States	33%	Atypical presentation patient: older, ↑ proportion of women and diabetics without a significant interaction between sex and diabetes (P = 0.30). HF comorbidities and less likely to have coronary intervention with bchance of anticoagulants, aspirin and β blocker usage
Canto et al[74]	434877 MI ptsJune 1994-March 1998	Prospective observational study United States	33% had no chest pain	Patients without chest pain on presentation: Likely to be diabetics (32.6% vs 25. 4%) Older (74.2 yr vs 66.9 yr). Likely to be female (49.0% vs 38.0%) Likely to have prior HF (26.4% vs 12.3%)Had a longer delay before hospital presentation (mean, 7.9 h vs 5.3 h) Less likely to be diagnosed with confirmed MI at the time of admission (22.2% vs 50.3%) Less likely to receive thrombolysis or PCI (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), BB (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). 23.3% in-hospital mortality vs 9.3% in patients with chest pain
Medalie et al[75]	9509 healthy adult subjects	Israeli Heart Attack study, cohort/ Israel	3.6 unrecognized MI/ 1000 persons and 5.3 clinical MI/1000 persons	By multivariate analysis, age, left axis deviation, LVH, cigarette smoking, systolic or diastolic BP, and PVD were the most significant risk factors. Cholesterol, DM, anxiety, and psychosocial problems, do not play a significant role in unrecognized MI
Brieger et al[76]	20881 ACS patients	Global Registry of Acute Coronary Events/multinational, prospective, observational study (in 14 countries)	8.4% presented without chest pain	23.8% not initially recognized as having an ACS, < 33% of the population with atypical symptoms were diabetics. Less likely to receive effective cardiac medications ahospital morbidity and mortality (13% vs 4.3%, respectively; P < 0.0001) ahospital mortality rates in patients with presenting symptoms of pre-syncope/syncope. Nausea or vomiting, dyspnea and in those with painless presentations of UA

^aIncrease/higher;

^bDecreased/lower. MI: Myocardial infarction; UA: Unstable angina; AMI: Acute myocardial infarction; ACS: Acute coronary syndrome; DM: Diabetes mellitus; SOB: Shortness of breath.