Beyond Chest Pain: Atypical Acute Coronary Presentations

Chest pain is a life-threatening emergency. We consider it part of the classic presentation for identifying a cardiac event. Yet depending on age, sex, and culture, chest pain may not be present when something goes wrong, or it may not be described as such. For example, 40% of men and 50% of women over 65 do not report having chest pain while having a myocardial infarction.

What else should you look for? Here are some other aspects of atypical acute coronary presentations.

Nausea and Vomiting

Nausea and/or vomiting have been described as symptoms by roughly 67% of patients having cardiac emergencies. Not all of them have chest pain.

Necrotic, ischemic, and injured cardiomyocytes from infarcted regions release metabolites such as lactic acid and pyruvic acid. These metabolites stimulate the autonomic nerve receptors. Think about it in the same way we see referred pain with splenic injury and left shoulder pain. For chest pain they share a common neuropathway with the abdomen. This stimulation leads to cardiogenic nausea and vomiting. When we see patients with nausea and vomiting, we should be on the alert for an MI.

Patient Age

Dyspnea, diaphoresis, nausea and vomiting, and syncope are the most frequent presenting signs of ACS in patients over 65. Older adults have higher mortality in ACS due to a failure to recognize and identify the episode. This may be due to the patient not experiencing any pain—or to EMS not performing the detective work necessary to uncover the root cause.

The “65/65 rule” reminds us that 65% of ST-elevation MIs occur in patients over 65 years of age. If you have a patient who presents with diaphoresis, nausea and/or vomiting, syncope, and/or shortness of breath, always get a 12-lead EKG—especially if they are 65 or older.

Another concern is elderly patients who present in CHF. Increased arterial stiffness, coupled with increased arterial pulse pressure, makes patients more prone to acute pulmonary edema with ACS. In this instance every elderly patient with CHF requires a 12-lead EKG.

Female Gender

The early research for myocardial infarction looked at predominantly white middle-aged men. These early case studies and the descriptions these patients reported became the basis for much of what we thought we understood regarding the presentation of myocardial infarction and ischemia. It shouldn’t be surprising, though, that how they described their pain was different than other ethnicities and women.

As women entered the workforce in increasing numbers since the 1980s, their rates of heart disease and death from heart disease equaled or exceeded men’s up until 2017 (it has since leveled off). American Heart Association data shows one woman every minute dies from heart disease in the U.S. An estimated 44 million American women are affected by coronary vascular disease, and 90% have one or more risk factors for it.

Female patients experience ACS differently than men. Presentations of cardiac pain for women can include vague signs and symptoms such as extreme fatigue, shortness of breath, nausea, back pain (sometimes described as discomfort in the shoulder blades), dizziness, and palpitations. These are significantly more common in women as descriptors of distress. Vigilance is the key for these patients; maintain a high index of suspicion. Suspect the worst and hope for the best.

Culture

In EMS there are biases, both implicit and explicit, that contribute to our understanding of pain and responses to patients. These biases may impede our ability to correctly assess patients for myocardial ischemia and infarction. There are studies that show disparities for Black and Latinx populations in treatment for pain and myocardial infarction and survival for cardiac arrest. This is unacceptable.

How a patient understands and relates to their own pain or the pain of a family member is often shaped by experience, learning, and culture. Some people, based on their upbringing, accept pain as a normal part of life. This will ultimately determine if they seek a medical solution to their problem. There are countless stories of patients who have had MIs for days before they sought treatment or, worse, succumbed to their infarct.

In some cultures there is resistance to seeking treatment because of misconceptions regarding outcomes. I have spoken with patients who said they didn’t seek care because they felt medical professionals didn’t take their concerns seriously. There are many rationales to different beliefs regarding the nature of pain and disability, and some are extremely complex.

Developing a one-culture approach to understanding and assisting patients in pain is myopic. In these instances, if you are not familiar with a particular culture and its beliefs and practices, you need to be a good detective. You aren’t trying to rule anything out, and nothing comes off the table—think of it as a search for the answer to a problem.

Diabetes

A reduction in oxygen-enriched blood to the heart that arises in the absence of chest pain is called a silent MI. These are commonly seen in diabetic patients but are not limited to them. Silent MI is a condition where other symptoms—for example, dyspnea, nausea, and diaphoresis—are not present as well. Generally diabetics have more extensive atherosclerotic disease, which affects the coronary arteries. This makes them more susceptible to cardiac events.

Diabetic neuropathy is a common side effect of diabetes that causes damage to the autonomic nervous system. This nerve damage can reduce your patient’s ability to feel the pain caused by reduced/absent blood flow in myocardial infarction or other coronary syndromes (e.g., angina).

For this reason I generally obtain a 12-lead on every diabetic and am never surprised when I find they are having a cardiac event.

Summary

There are many factors that may influence our assessment of the patient with subtle signs and symptoms of ACS. Female patients are at greater risk because they use different descriptors to identify their distress. Elderly patients and diabetics may be more prone to having a myocardial event without the classic sign of chest pain. Populations of color suffer disproportionately in how their pain is managed and how cardiac events are perceived. This places them at greater risk for death. Different cultures will relate to pain and understand it differently than you may. For any of these patients, we aren’t trying to rule anything out—that is not our job. We are in search of an answer.

Resources

Benjamin EJ, Muntner P, Alonso A, et al.; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation, 2019 Mar 5; 139(10): e56–e528.

Berg J, Björck L, Dudas K, Lappas G, Rosengren A. Symptoms of a first acute myocardial infarction in women and men. Gend Med, 2009 Sep; 6(3): 454–62.

Carro A, Kaski JC. Myocardial infarction in the elderly. Aging Dis, 2011; 2(2): 116–37.

Engberding N, Wenger NK. Acute Coronary Syndromes in the Elderly. F1000Res, 2017 Oct 2; 6: 1,791.

Fuller EE, Alemu R, Harper JF, Feldman M. Relation of nausea and vomiting in acute myocardial infarction to location of the infarct. Am J Cardiol, 2009 Dec 15; 104(12): 1,638–40.

Hewes HA, Dai M, Mann NC, Baca T, Taillac P. Prehospital Pain Management: Disparity By Age and Race. Prehosp Emerg Care, 2018 Mar–Apr; 22(2): 189–97.

Janand-Delenne B, Savin B, Habib G, et al. Silent myocardial ischemia in patients with diabetes: who to screen. Diabetes Care, 1999 Sep; 22(9): 1,396–400.

Kennel J. Investigating EMS Treatment Disparities by Patient Race/Ethnicity for Traumatic and Painful Emergencies. Oregon Health and Sciences University, 2018 May 31; www.ohsu.edu/sites/default/files/2018-08/EMS-Treatment-Disparities.pdf

Kennel J, Withers E, Parsons N, Woo H. Racial/Ethnic Disparities in Pain Treatment: Evidence From Oregon Emergency Medical Services Agencies. Med Care, 2019 Dec; 57(12): 924–9.

Peacock S, Patel S. Cultural Influences on Pain. Rev Pain, 2008; 1(2): 6–9.

Pezzin LE, Keyl PM, Green GB. Disparities in the emergency department evaluation of chest pain patients. Acad Emerg Med, 2007 Feb; 14(2): 149–56.

Saunderson CED, Brogan RA, Simms AD, et al. Acute coronary syndrome management in older adults: guidelines, temporal changes and challenges. Age and Ageing, 2014 Jul; 43(4): 450–55.

Zhao D, Post WS, Blasco-Colmenares E, et al. Racial Differences in Sudden Cardiac Death. Circulation, 2019 Apr 2; 139(14): 1,688–97.

Daniel R. Gerard, MS, RN, NRP, is EMS coordinator for Alameda, Calif. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.