Pinto David, Lunet Nuno, Azevedo Ana
Serviço de Higiene e Epidemiologia, Faculdade de Medicina da Universidade do Porto, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal.
Acta Med Port. 2011 Dec;24 Suppl 2:307-18. Epub 2011 Dec 31.
Knowledge of the characteristics of patients with atypical presentation of acute coronary syndromes may contribute to increased sensitivity in diagnosis in a given population. The purpose of this study is to quantify the prevalence of atypical presentation, to identify its determinants, and to describe the presenting symptoms in cases of acute coronary syndrome at the emergency department of Hospital São João, Porto.
Systematic sample of 288 emergency admissions with a confirmed diagnosis of acute coronary syndrome in 2007. Atypical presentation was defined as absence of chest pain and/or syncope.
The prevalence of atypical presentation was 20.5% [95% confidence interval (CI): 16.0 to 25.5], with no important variation by gender. It increased with age and was more frequent in cases of ST-segment elevation myocardial infarction. In multivariate analysis, atypical presentation was associated with age [>70 versus ≤ 50 years, odds ratio (OR)=3.45; 95%CI: 1.03-11.61] and it was about four times less likely in the presence of history of ischemic heart disease, hypertension, dyslipidemia and smoking. A history of heart failure was independently associated with a higher likelihood of acute coronary syndrome with atypical presentation (OR = 4.15, 95%CI 1.50-11.46). Among the 223 cases who had chest pain or discomfort, a growing, oppressive, prolonged (longer than 30 minutes), recurrent and episodic pain prevailed. Among other symptoms, dyspnea was the most frequently reported, either as the main symptom in cases of atypical presentation or concurrently with typical symptoms.
Factors associated with atypical presentation are consistent with those described in other populations. Using routine clinical data allowed access to a large data base on a representative sample of patients admitted to the emergency department of a third-level hospital that serves a large part of the local urban population. In medical records, data are unstandardized and heterogeneous in validity and detail.
One fifth of the episodes of acute coronary syndrome have atypical presentation, and this proportion is higher in older ages. Previous history of ischemic heart disease or its classical risk factors are associated with typical symptoms, while heart failure is associated with atypical presentation. Presentation in atypical cases is highly variable and does not allow the identification of a pattern that would justify lowering the threshold for suspicion of acute coronary syndrome.
了解急性冠状动脉综合征非典型表现患者的特征，可能有助于提高特定人群的诊断敏感性。本研究的目的是量化非典型表现的患病率，确定其决定因素，并描述波尔图圣若昂医院急诊科急性冠状动脉综合征病例的症状表现。
对2007年确诊为急性冠状动脉综合征的288例急诊入院患者进行系统抽样。非典型表现定义为无胸痛和/或晕厥。
非典型表现的患病率为20.5%[95%置信区间（CI）：16.0至25.5]，性别间无显著差异。患病率随年龄增长而增加，在ST段抬高型心肌梗死病例中更为常见。多因素分析显示，非典型表现与年龄相关[>70岁与≤50岁相比，比值比（OR）=3.45；95%CI：1.03 - 11.61]，而有缺血性心脏病、高血压、血脂异常和吸烟史的患者出现非典型表现的可能性约低四倍。心力衰竭病史与急性冠状动脉综合征非典型表现的可能性增加独立相关（OR = 4.15，95%CI 1.50 - 11.46）。在223例有胸痛或不适的病例中，进行性、压迫性、持续性（超过30分钟）、反复性和发作性疼痛较为常见。在其他症状中，呼吸困难是最常报告的症状，无论是在非典型表现病例中作为主要症状，还是与典型症状同时出现。
与非典型表现相关的因素与其他人群中描述的因素一致。利用常规临床数据可以获取来自一家为当地大部分城市人口服务的三级医院急诊科患者代表性样本的大型数据库。在医疗记录中，数据未标准化，有效性和细节存在异质性。
五分之一的急性冠状动脉综合征发作有非典型表现，且这一比例在老年人中更高。既往缺血性心脏病史或其经典危险因素与典型症状相关，而心力衰竭与非典型表现相关。非典型病例的症状表现高度可变，无法确定一种模式来证明降低对急性冠状动脉综合征怀疑阈值的合理性。
