Junghans Cornelia, Sekhri Neha, Zaman M Justin, Hemingway Harry, Feder Gene S, Timmis Adam
Department of Epidemiology and Public Health, University College London, London, UK.
Barts Health, London Chest Hospital, London, UK.
Eur Heart J Qual Care Clin Outcomes. 2015 Jul 1;1(1):37-43. doi: 10.1093/ehjqcco/qcv003.
Silent myocardial ischaemia occurs commonly in diabetes. Whether altered perception of ischaemia also predisposes to atypical presentations with under-diagnosis of coronary disease is not known. To determine whether (i) patients with diabetes diagnosed with angina are more likely to report atypical symptoms compared with patients without diabetes, and (ii) atypical symptoms in patients with diabetes cause angina to go unrecognized, increasing the risk of coronary events.
Prospective, multicentre cohort study of 8662 ambulatory patients with suspected angina, of whom 906 had diabetes. We recorded detailed chest pain descriptors and fatal and non-fatal coronary events over a median of 3.08 years of follow-up. Proportionately more patients with than without diabetes received a diagnosis of angina (42.7 vs. 25.1%). Among patients with diabetes diagnosed with angina, a greater proportion had atypical chest pain compared with patients without diabetes (21.0 vs. 11.3%), but the hazard of fatal and non-fatal coronary events was similar. However, among patients diagnosed with non-cardiac chest pain, those with diabetes-most of whom had atypical symptoms-remained at greater risk of coronary events [2.29 (95% CI 1.54, 3.41)] and all-cause mortality [1.67 (95% confidence interval, CI 1.04, 2.69)] compared with non-diabetic patients.
Patients with diabetes and atypical symptoms are nearly twice as likely to be diagnosed with angina compared with non-diabetic patients. Those diagnosed with non-cardiac pain are at increased risk of coronary events. Our study emphasizes the need for more intensive investigation of diabetic patients with chest pain, particularly those presenting with atypical symptoms.
无症状性心肌缺血在糖尿病患者中很常见。目前尚不清楚对缺血的感知改变是否也易导致冠心病诊断不足的非典型表现。以确定：（i）与非糖尿病患者相比，诊断为心绞痛的糖尿病患者是否更有可能报告非典型症状；（ii）糖尿病患者的非典型症状是否会导致心绞痛未被识别，从而增加冠状动脉事件的风险。
对8662例疑似心绞痛的门诊患者进行前瞻性、多中心队列研究，其中906例患有糖尿病。我们记录了详细的胸痛描述以及在中位3.08年的随访期间的致命和非致命冠状动脉事件。与非糖尿病患者相比，糖尿病患者中被诊断为心绞痛的比例更高（42.7%对25.1%）。在被诊断为心绞痛的糖尿病患者中，与非糖尿病患者相比，有更大比例的患者有非典型胸痛（21.0%对11.3%），但致命和非致命冠状动脉事件的风险相似。然而，在被诊断为非心源性胸痛的患者中，糖尿病患者（其中大多数有非典型症状）与非糖尿病患者相比，冠状动脉事件风险[2.29（95%可信区间1.54，3.41）]和全因死亡率[1.67（95%可信区间，CI 1.04，2.69）]仍然更高。
与非糖尿病患者相比，有非典型症状的糖尿病患者被诊断为心绞痛的可能性几乎高出一倍。那些被诊断为非心源性疼痛的患者发生冠状动脉事件的风险增加。我们的研究强调需要对有胸痛的糖尿病患者，特别是那些有非典型症状的患者进行更深入的检查。
