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Dr K K Aggarwal

Younger women with acute coronary syndromes may not have classic chest pain

By Dr K K Aggarwal
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Younger women with an acute coronary syndrome are slightly less likely than men to present with the classic symptom of chest pain, according to a study published in JAMA Internal Medicine. As a result, they often fail to receive a correct diagnosis in the emergency department.

Nadia Khan and colleagues prospectively analyzed data from more than 1,000 ACS patients 55 years of age or younger– 30% of whom were women– participating in the GENESIS PRAXY study.

In these younger patients women were less likely to have chest pain than men (19% of women versus 13.7% for men, p = 0.03).

Women were also more likely than men to have a non-ST-segment elevation myocardial infarction (37.5% vs 30.7%; p = 0.03).

Upon multivariate analysis, women and patients with tachycardia were less likely to have chest pain. The absence of chest pain did not herald any change in the type or severity of the ACS.

Diagnosis of any disease with a lower prevalence but higher mortality, such as coronary artery disease in younger women, is more challenging.

Public health messages should “target both men and women regarding ACS symptom presentation with or without chest pain so as to encourage earlier and more widespread access to appropriate and lifesaving care.

Premature heart disease is when heart disease occurs before 55 years in men and 65 years in women. In premature heart disease, the prevalence of dyslipidemia (high cholesterol levels without symptoms) is 75-85%. Fifty-four percent of all patients with premature heart disease and 70% of those with a lipid abnormality have a familial disorder. Hence, a screening test for lipids is recommended for first-degree relatives of patients with myocardial infarction, particularly if premature. Screening should begin with a standard lipid profile and if normal, further testing should be done for Lp(a) and apolipoproteins B and A-I. About 25% patients with premature heart disease and a normal standard lipid profile will have an abnormality in Lp(a) or apo B. Elevated apo A-1 and HDL are likewise associated with reduced CHD risk. First-degree relatives are brothers, sisters, father, mother; second-degree relatives refer to aunts, uncles, grandparents, nieces, or nephews and third-degree relatives refer to first cousins, siblings, or siblings of grandparents. Familial hypercholesterolemia (FH) is a genetic disorder, characterized by high cholesterol, specifically very high LDL (“bad cholesterol”) levels and premature heart disease. Patients may develop premature cardiovascular disease at the age of 30 to 40. Heterozygous FH is a common genetic disorder, occurring in 1:500 people in most countries. Homozygous FH is much rarer, occurring in 1 in a million births. Heterozygous FH is normally treated with drugs. Homozygous FH often does not respond to medical therapy and may require apheresis or liver transplant. To detect familial high cholesterol levels, a universal screening must be done at age 16. The cholesterol levels in heterozygous patients are between 350 to 500 mg/dL, and in homozygous, the levels are between 700 to 1,200 mg/dL.

Longer duration of chest pain means bigger MI risk

By Dr K K Aggarwal
Filed Under Wellness | Tagged With: , , , | | Comments Off on Longer duration of chest pain means bigger MI risk

Patients with acute myocardial infarction have longer duration of chest pain than those without a myocardial infarction. Patients with chest pain of short duration, less than 5 minutes, are unlikely to have an acute infarction and have a good prognosis at 30 days. A single–center study showed that only 8.9% of the patients received a final diagnosis of acute MI, and these patients had a significantly longer duration of chest pain compared with the rest of the cohort (120 versus 40 minutes) according to Carlos Calle–Muller, MD, of Henry Ford Hospital in Detroit, and colleagues. Those who had chest pain lasting less than 5 minutes always had a good outcome, with no acute MIs or deaths within 30 days, as reported in the journal Critical Pathways in Cardiology. If the clinical assessment and ECG are benign, such patients might be able to be discharged directly from the emergency department without stress testing for outpatient follow-up. The median chest pain duration was 180 minutes among the 10 patients who died and only 40 minutes for the others. Among patients with acute MI, longer chest pain duration was not associated with higher 30–day mortality, but it was associated with a higher initial level of cardiac troponin-I.