Int J Clin Cardiol ISSN: 2378-2951

• Abstract
• Keywords
• Introduction
• Method
• Results
• Discussion
• Study Limitation
• Implications for Practice
• Conclusion
• Author contribution
• Acknowledgments
• Conflict of interest
• Funding
• Table 1
• Table 2
• Table 3
• References

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International Journal of Clinical Cardiology

¹Assistant Professor, Department of Surgical Nursing, Aydin School of Health, Adnan Menderes University, Turkey
²Lecturer, Faculty of Midwifery and Nursing, Shahed University, Iran
³Assistant Professor, Faculty of Midwifery and Nursing, Shahed University, Iran

Abstract

Acute coronary syndromes (ACS) are the leading cause of death in older adults. Early recognition of symptoms suggestive of ACS by the emergency triage nurse can improve patient outcomes. The aim of this study was to determine risk factors associated with typical and atypical symptoms in older and younger patients with ACS. This prospective study was performed on 446 patients who admitted at the Emergency Department of Tehran Medical Affiliated Hospital. Patients were considered for participation if they had undergone treatment with diagnoses of ACS based on confirmed electrocardiography changes, cardiac enzyme (CPK-MB), and had ≥ 1 of a set of typical symptoms of ACS. Patients with a history of cerebrovascular accident, heart failure, congestive occlusive pulmonary diseases, pneumonia and pulmonary embolism are excluded. Patients distributed in older ( ≥ 65 years) and younger (< 65 years) groups. Older patients had a statistically significant difference in typical symptoms such as chest pain, arm pain, jaw/neck pain and dyspnea compare to younger patients (P < 0.05). Older patients had no significant difference in atypical symptoms compared to younger patients (P > 0.05). Older or younger patients with a history of hypertension (OR 0.43, CI 0.25 - 0.73, P = 0.002), smoking (OR 0.51, CI 0.30 - 0.89, P = 0.019) and obesity (OR 0.69, CI 0.51 - 0.10, P = 0.011) have less chance to experience typical symptoms of ACS. Understanding the typical symptoms of ACS and factors related that may help in the early detection and more appropriate medical treatments in patients with ACS.

Keywords

Acute coronary syndrome, Typical Symptoms, Atypical symptoms, Elderly

Introduction

Acute coronary syndrome (ACS) is health-threatening and a major cause of mortality in elderly [1-4]. ACS encompasses a spectrum of coronary artery diseases (CAD), including unstable angina, ST-elevation myocardial infarction and non-ST elevation myocardial infarction with initial presentation and early management [5]. Diagnosis of ACS in older patients is difficult and it related to natural and pathological changes associated with elderly [6]. Wall thickening and dilatation are prominent structural changes that occur within large elastic arteries during aging. Age-associated changes in arterial properties of individuals who are otherwise considered healthy may have relevance to the exponential increase in ACS [7]. Increased age has been identified as an important risk factor for adverse events and complications of ACS and treatment. Complication and mortality rate related to ACS have increased with age [8]. Sixty percent of all deaths due to acute myocardial infarction are reported in older patients and mortality is about three times more than younger patients [9]. The results of Gillis et al. (2013) study showed that older adults with ACS have higher in-hospital mortality rates than adults aged younger than 65 years.

ACS is characterized by typical and atypical symptoms. Typical symptoms include chest pain, arm pain, shortness of breath, sweating and jaw/neck pain. Atypical symptoms include fainting, weakness, palpitation, nausea/vomiting, mid-back pain, numbness/tingling in the chest, loss of consciousness and gastrointestinal complaints. Patients with ACS mostly present typical chest pain. Atypical symptoms are seen more among older patients [10]. Absence of the typical symptoms is the most important factor for not using thrombolytic therapy and increased hospital mortality [11]. Delay in time in arrival to the hospital, as well as delay to primary percutaneous intervention, is reported for older adults with and without typical symptoms. 2 Identifying the symptoms of ACS is important for successful management. Furthermore, understanding the factors related to symptoms may help in the early detection and appropriate medical treatments [11-13]. Many studies have described the association of risk factor such as hypertension, dyslipidemia and smoking with ACS [12-16]. But there are limits researches about association of risk factors of typical and atypical symptoms of ACS in older or younger patients [12,17]. The aim of this study was to determine risk factors associated with typical and atypical symptoms in older and younger patients with ACS.

Method

This prospective study was conducted between March 2011, and June 2012 at the Emergency Department (ED) of a medical affiliated hospital. Patients were eligible for inclusion if they had undergone treatment with diagnoses of ACS (STEMI, NSTEMI or unstable angina) based on confirmed electrocardiography changes, cardiac enzymes (CPK-MB), and patients who had ≥ 1 of a set of typical symptoms of ACS. Typical symptoms of ACS were chest symptoms (pain below the sternum or on the left chest), arm pain, diaphoresis, jaw/neck pain and dyspnea. Atypical symptoms were fatigue/weakness, palpitation, nausea/vomiting, mid-back pain, chest pain in another location (numbness, tingling, pricking, or stabbing in chest), and indigestion. Samples of study distributed in older ( ≥ 65 years) and younger group ( < 65 years). Patients with a history of cerebrovascular accident, heart failure, congestive occlusive pulmonary diseases, pneumonia and pulmonary embolism are excluded. According to the results of a pilot study with p = 0,3 and d = 0,04, a selection of 530 patients were sufficient for the sample. Of these, 446 patients agreed to participate and enrolled in this study.

Data collecting instrument was developed based on a review of literature and from the specialist's comments. Specialists included one ED physician, one ED nurse specialist, two ED staff nurses, one cardiologist, and a cardiac clinical nurse specialist. Check list consists of symptoms which divided to two typical and atypical symptoms categories. The authors categorized all extracted symptoms to typical and atypical symptoms based on Milner Classification [18]. Data collecting was conducted during shifts of 6 hours across all 24 hours and all 7 days, and 8 nurse data collectors observed all the patients who met the study criteria as they admitted to the ED. ACS was defined as either unstable angina or acute myocardial infarction, confirmed by electrocardiography changes (ST-segment and T-wave changes) and cardiac enzyme (CPK-MB). For more unified data collection, investigator interviewed and trained nurses before beginning the study and practices on number of patients for confidence of accurate procedure. Data on presenting symptoms were obtained by observing the patient-nurse interview, and related symptoms of ACS expressed by the patient were documented in ACS symptoms check list. Demographics variables such as sex, age and risk factors such as history of hypertension, hypercholesterolemia, diabetes, currently smoking and obesity were collected from the medical records. Obesity is considered as BMI ≥ 30.

The study was approved by the Institutional Ethics Committee of the Shahed University in Tehran. Written approvals were obtained from the Shahed University Institute of Health Sciences (March, 2010), Ethics Board of the Shahed University Midwifery and Nursing Faculty (May, 2010), Tehran Medical Affiliated Hospital (June, 2010). Written and verbal informed consent was obtained from all patients after explaining the aims and protocol of the study.

The data analysis was performed by using SPSS version 16.0 (Statistics for Social Sciences) for windows statistics program. To examine the associations between ACS and baseline characteristics and also typical/atypical symptoms in younger and older patients, chi-squared test were used. Symptoms that reported by at least 5% were included in the bivariate analyses. To determine risk factors related to typical and atypical symptoms of ACS between older and younger the method of multiple logistic regressions with stepwise was performed. Adjusted Odd ratios were estimated for each risk factor. Statistical significance was set at p < 0.05.

Results

Among the 446 patients 66.6% (n = 297) of them were in the older and 33.4% (n = 149) in the younger group. The mean age of patients was 67.13 ± 8.79 years. The mean age of older patients was 71.32 ± 3.81 yr and younger patients were 53.57 ± 8.07. Results showed a significant difference in risk factors such as smoking (P = 0.002), obesity (P = 0.019) and hypertension (P = 0.002) between younger and older patients. The results did show a significant difference in type of ACS by age groups (P < 0.01) (Table1).

The most typical symptom in older patients was dyspnea (36.7%) and the lowest was jaw/neck pain (6.74%). The most atypical symptom in older patients was palpitation (38.89%) and the lowest were indigestion (3.47%) and chest pain in another location (3.47%), respectively. The chi-square test showed that younger and older patients have statistically significant difference in typical symptoms such as chest symptoms (P = 0.027), arm pain (P = 0.033), jaw/ neck pain (P = 0.001) and dyspnea (P = 0.048). However, there were no significant differences between atypical symptoms between older and younger (P > 0.05) (Table 2).

In multivariate logistic regression analysis, hypertension, smoking and obesity had significant contribution (P < 0.05) in the typical symptoms of ACS between older and younger patients. Older and younger patients with a history of hypertension (OR 0.43, 95% CI 0.25 - 0.73, P = 0.002), smoking (OR 0.51, 95% CI 0.30-0.89, P = 0.019), and obesity (OR 0.69, 95% CI 0.51-0.10, P = 0.011) have less chance to experience typical symptoms of ACS (Table 3).

Discussion

ACS is a major cause of mortality in elderly [2,5,6]. Identifying the symptoms of ACS and factors related to these symptoms are important for successful management and may help in the early detection and appropriate medical treatments [11-13]. Age is an important determinant of outcomes for patients with ACS [14]. Symptoms, which are a key component in the patient's decision to seek care, are critical to appropriate triage, and influence the decision on whether to pursue further evaluation and initiation of treatment [9,15]. The primary complaint of the patients with ACS is characterized predominantly by chest pain. However, a substantial number of patients may have atypical or no symptoms on initial evaluation. Atypical symptom indicates that the patient's chief complaint is not chest pain, but other gastrointestinal or respiratory symptoms with less intense chest pain [12,18].

Our study results showed a significant difference in the typical symptoms of ACS between older and younger patients. Dominant typical symptom in older patients was dyspnea. Also, the results of some studies showed that a higher prevalence of dyspnea in older patients [19-24].

This study showed that chest pain is more likely in younger than older patients. Also, in some investigations chest pain was more likely in younger patients [15,24]. Similarly, studies showed that chest pain significantly reduced in older patients, but, some studies suggested atypical symptoms such as dizziness/syncope, indigestion, and weakness is more frequent in older patients [11,13,20,21,23,25-27]. Similar to this study, Milner et al. did not find a significant difference about atypical symptoms between older and younger patients with ACS [18]. Gillis et al. study showed that older adults reporting an absence of chest pain on arrival are twice as likely to die compared with older adults with chest pain2. According atypical symptoms, our study results showed no significant difference in atypical symptoms between older and younger patients, but a dominant atypical symptom in the both patients groups was palpitation.

At the present study, patients with typical symptoms such as chest pain, arm pain, jaw/neck pain, dyspnea were more likely to be hypertensive, obese and smokers. Also, diabetes and hypercholesterolemia were not predictors of typical symptoms in older or younger patients. Hwang showed that diabetes is not a predictor in the whole patient group with atypical symptom [22]. In Langer study, diabetic patients have impaired perception of symptoms such as chest pain [28]. Hasin showed patients with diabetes have a less typical presentation [29]. In this research, in contrast of Hwang study (2009) there was a correlation between female gender and early symptoms. It is assumed, beside to physiological and pathological changes related to aging, older women are likely more affected by chronic condition or risk factors. Canto has found that smoking and hypercholesterolemia were associated with chest pain [30]. Also, this study findings showed the effect of smoking on typical symptoms of ACS. However, this effect is not observed for hypercholesterolemia. Pinto reported that in elderly atypical symptoms is about four times less likely in the presence of hypertension, dyslipidemia and smoking [31]. This study findings suggest that older or younger patients with ACS have less typical symptoms in the presence of hypertension, smoking and obsity.

The results of this study showed the effects of some risk factors on how to report typical symptoms of ACS. Initial assessment and risk classification probably will challenged in being of some risk factors such as obesity, hypertension and smoking. It is recommended to investigate the interactive effects of multiple risk factors on reporting symptoms of ACS.

Study Limitation

In this study several emerging risk factors such as lipoprotein abnormalities, hypercoagable states, elevated homocysteine levels, markers of inflammation and platelet glycoprotein were not evaluated. Furthermore, subgroup analysis about symptoms of older or younger patient groups with STEMI, NSTEMI and unstable angina were not evaluated.

Implications for Practice

• Diagnosis of ACS in older patients is difficult due to natural and pathological changes associated with elderly. Identifying the symptoms of ACS is important for successful and immediate treatment.

• Chronic diseases and age-specific physiological and pathological features can affect the presentation of symptoms of ACS in the elderly. Understanding the factors related to symptoms may help in the early detection and more appropriate medical treatments of the patients with acute coronary syndrome.

• Symptoms of ACS is affected by risk factors. Older and younger patients with a history of risk factor such as obesity, hypertension and smoking have less chance to experience the typical symptoms.

• One of the important tasks of clinical treatment and care providers is obtaining an accurate history of the patient with cardiac complaints. Identifying the symptoms of ACS is important for successful and immediate treatment.

• To findings suggest very carefully examining in the history taking from patients suspected of cardiac ischemic problems at emergency departments.

Conclusion

The results of this study showed that the typical symptoms such as chest pain, arm pain, jaw/neck pain and dyspnea were more predictive of ACS in older than younger patients. Identifying the symptoms of ACS is important for successful and immediate treatment. Accurate diagnosis of ACS could reduce hospital mortality and morbidity. In this study, it seems typical symptoms of ACS in older or younger patients are affected by risk factors such as obesity, hypertension and smoking. Clinical treatment and care providers need to very carefully examine any patients suspected of ACS with a history of risk factors.

Author contribution

HA, RN and and MRH were responsible for the study conception and design and drafting of the manuscript.

Acknowledgments

The authors thank the staffs of EDs and patients who helped us in conducting this research.

Conflict of interest

None of the authors has any potential conflicting interest in this study.

Funding

This study is supported by Shahed University, Tehran, Iran.

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