Symptoms at NSTEMI presentation - do they predict the outcome?
Authors: Araujo Leite Medeiros P , Martins J , Oliveira C , Pires C , Flores R , Mane F , Silva R , Conde I , Gaspar A , Azevedo P , Marques J 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
The most common clinical presentation of non-ST-segment elevation myocardial infarction (NSTEMI) is angina pectoris. However, some groups of patients such as elderly, women and patients with diabetes or chronic renal disease,may have atypical symptoms, like isolated dyspnea or syncope.

Aim
The aim of this study was to identify the outcomes of NSTEMI patients with different types of presenting symptoms and to verify if these presentations were independent predictors of the studied outcomes.

Methods
We studied patients &gt;18 year-old admitted with NSTEMI between October 2010 and September 2019. Data was collected from a national multicentric registry. From an initial pool of 13739 patients, a total of 4726 were included (the main exclusion criterion was lack of follow-up registry). The patients were divided into 3 groups according to the main presentation symptom: group 1 – chest pain; group 2 – dyspnea/fatigue; group 3 – syncope. The primary endpoint was 1-year death from any cause.

Results
The most common presentation sympton was chest pain (91.3%; n=4313), followed by dyspnea/fatigue (7%; n=332) and syncope (1.7%; n=81). Seventy-one percent (n=3352) of patients were male and 29.1% (n=1374) female. Mean age was 68±13 years. Patients presenting with dyspnea/fatigue were older (75±11 vs 68±13 [group 1] vs 74±13 [group 3], p&lt;0.001), more commonly women (41.9% vs 29.1% [group 1] vs 37% [group 3], p&lt;0.001), with hypertension (89.5% vs 74.8% [group 1] vs 75% [group 3], p&lt;0.001), diabetes mellitus (54.6% vs 33.7% [group 1] vs 38.3% [group 3], p&lt;0.001), chronic kidney disease (18.1% vs 6.8% [group 1] vs 11.5% [group 3], p&lt;0.001, and chronic obstructive pulmonary disease [COPD] (15.5% vs 5.9% [group 1] vs 10.3% [group 3], p&lt;0.001). They also had worse Killip class at admission (KK&gt; 1 80% vs 9.9% [group 1] vs 23.5% [group 3], p&lt;0.001). One-year survival rate was lowest patients presenting with dyspnea/fatigue (75.7% vs 93.5% [group 1] vs 92.1 [group 3], p&lt;0.001) and 1-year free from cardiovascular rehospitalization was also lowest in this group (75.6% vs 85% [group 1] vs 83.3% [group 3], p&lt;0.001). However, after multivariate analysis, the different presenting symptoms were not significant independent predictors of the primary endpoint; identified independent predictors included age (HR 3.37, 95% CI 2.111 to 3.815, p&lt;0.001), COPD (HR 2.508, 95% CI 1.584 to 3.969, p&lt;0.001), LVEF &lt; 50% (HR 2.350, 95% CI 1.642 to 3.365, p&lt;0.001), and major bleeding (HR 4.66, 95% CI 2.118 to 10.254, p&lt;0.001).

Conclusion
This study reveals that patients with dyspnea/fatigue at presentation have an overall worse prognosis than those who present with chest pain or syncope. The former patients were more commonly women, older and had more comorbidities; also, they presented with worse Killip class. However, symptoms themselves were not independent predictors of 1-year mortality.