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128 Cardio Diabetes Medicine 2017

Atypical Presentation of Acute

Coronary Syndrome in Diabetics

Dr. T. Neelambujan, MD., DNB., FESC., FCSI., FIAE.
Consultant Cardiologist & Interventionalist,
Sundaram Arulrhaj Hospitals, Tuticorin

INTRODUCTION Variables ODD rates (95% confiden-
It is predicted that 366 million patients globally will tial interval
have diabetes mellitus by 2030. Cardiovascular mor- Nonwhite 1.05 (1.03 - 1.07)
tality is the main cause of death in diabetics. There is
an estimated two to four fold higher risk of cardiovas- Women 1.06 (1.04 - 1.08)
cular events in diabetics compared to non-diabetics. Diabetes mellitus 1.21 (1.19- 1.23)
Age (10 year interval) 1.28 (1.26 - 1.28)
ATYPICAL SYMPTOMS OF ACUTE Prior stroke 1.43 (1.40 - 1.47)
CORONARY SYNDROME(ACS) : Prior Heart Failure 1.77 (1.74 - 1.81)
Chest pain is the cornerstone symptom of ACS.
However diabetic patients are also more frequently PROFILE OF PATIENTS WITH ATYPICAL
asymptomatic with a wide range of atypical presenta- PRESENTATION
tions which makes the diagnosis of ACS challenging.
In the National Registry of Myocardial Infarction 2
Atypical presentation is defined as the absence of (NRMI 2) study, a prospective observational study
chest pain before or during admission and may have from United States which included 4,34,8777 patients
included gastrointestinal or respiratory symptoms. with acute myocardial infarction, 33% were without
The common atypical symptoms encountered in clin- chest pain on presentation to the hospital and were 7
ical practice are: years older than those with chest pain (74.2 years Vs
1. Dyspnea (19.3%) 66.9 years). Patients with atypical presentation were
more likely to be females (32.6% Vs 25.4%) or previ-
2. Diaphoresis (26.2%) ous cardiac failure (26.4% Vs 12.3%) and had delayed
3. Nausea and Vomiting (24.3%) presentation(7.9 Vs 5.3 hrs).

4. Syncope (19.1%) The Global Registry of Acute Coronary Events (GRACE
Study) is the largest multinational prospective ob-
5. Abdominal discomfort servational study. Atypical presentation was seen in
6. Sudden cardiac death 5.7% of unstable angina and 12.3% non ST elevation
MI patients. Of the 20,881 patients in this study 8.4%
7. Silent myocardial ischaemia presented without any chest pain and 23.8% were not
INDEPENDENT RISK FACTORS FOR ATYPICAL PRE- initially recognized a shaving ACS. The patients with
SENTATION atypical presentation had higher hospital morbidity
and mortality (13% Vs 4.3% respectively ; P<0.00001)
In NRMI – 2 registry, variables such as older age, gen- and were less likely to receive effective cardiac med-
der, race and co-morbidities were considered as risk ications than patients with typical presentation. High-
factors for atypical symptoms.
er inhospital mortality were seen in patients who pre-
sented with presyncope / syncope(OR=2.0), Nausea
or vomiting (OR=1.6) and dyspnea (OR=1.4). In addition

GCDC 2017