Chest pain characteristics and their ability to predict NSTEMI according to gender and age in patients presenting with suspected ACS
Authors: Steiro O T S , Aakre K M A , Tjora H L T , Bjoerneklett R O B , Skadberg O S , Bonarjee V V S B , Mjelva O R M , Omland T O , Vikenes K V , Langoergen J L ,   WESTCOR
Published: October 2021

Abstract

Background
The epidemiologic panorama of acute myocardial infarction (AMI) has changed during the past decades with a lower rate of ST elevation myocardial infarction (STEMI) and higher rate of non-ST elevation myocardial infarction (NSTEMI). Most studies on presenting symptoms in patients with AMI include high rates of STEMI patients and were performed during a time when high-sensitivity cardiac troponin assays (hs-Tn) were not available. Hence, our knowledge on typical symptoms and their ability to predict AMI may not apply to the majority of today's patients in the emergency departments (ERs).

Purpose
Report chest pain characteristics and additional symptoms in patients presenting with suspected acute coronary syndrome (ACS) without ST elevations in a contemporary cohort diagnosed with hs-Tn. Assess the risk of having an NSTEMI based on symptom characteristics for women, men and patients ≥ and &lt;70 years of age and evaluate the strength of associations between symptom and gender or age category.

Methods
A total of 1506 patients &gt;18 years admitted with suspected ACS without ST elevation were included in the WESTCOR study from Sept. 2015 to May 2019. Diagnoses were adjudicated by two independent cardiologists. Information about symptoms was retrospectively collected from electronic medical records. Odds ratios (OR) for NSTEMI were calculated for all symptoms, and logistic regression was used to assess the interaction between genders and age groups ≥ and &lt;70 years of age.

Results
66.8% of all patients presented with both typical location and character. More women than men presented with atypical location (9.4 vs 6.8%, p&lt;0.001) while more men presented with atypical character (21.1 vs 17.9%, p=0.004). Women significantly more often than men reported radiating pain and typical additional symptoms (figure). Differences between age groups were most often non-significant.
Both genders and age groups had significantly increased odds of NSTEMI if pain radiated to both arms, was triggered by physical activity or happened in the course of chest pain prodromes, see table. Men had significantly lower OR for AMI compared to women if pain was dependent of position, respiration or palpation (OR 0.17 vs 0.53, p-value for interaction 0.047). Younger patients had significantly lower OR for NSTEMI compared to older patients if pain radiated to the left arm (OR 0.73 vs 1.67, p-value for interaction 0.045) and higher OR if exertional chest pain had been present during the last week prior to admission (OR 4.08 vs 1.81, p-value for interaction 0.025). We did not find that women had higher risk of NSTEMI if they presented with atypical pain compared to men (OR 0.50 vs 0.72, not significant).

Conclusion
Radiation to both arms has the strongest predictive value for NSTEMI. We do not find that women or older patients have higher odds ratio for NSTEMI if they present with atypical symptoms.

Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Grieg Foundation Incidence of symptomsIncidence and OR for NSTEMI