Goldstein R E, Boccuzzi S J, Cruess D
Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814-4799, USA.
Am J Med. 1995 Aug;99(2):123-31. doi: 10.1016/s0002-9343(99)80131-4.
Although ischemic-type chest pain generally identifies acute myocardial infarction (AMI), some patients are hospitalized for AMI without this symptom. Long-term mortality and morbidity after AMI presenting with alternative warning symptoms have not been examined previously. We therefore assessed the prognostic implications of the absence of typical chest pain as well as other recognized risk predictors in patients hospitalized with AMI.
Data were obtained during the Multicenter Diltiazem Postinfarction Trial. Pain status and other baseline characteristics were determined prospectively by study coordinators according to simple, prespecified criteria. Patients were then examined every 3 to 4 months until trial completion. We applied chi-square methods, life-table analysis, and multivariate analysis to assess the strength and independence of prognostic power associated with each baseline variable.
Of 2,464 patients enrolled 3 to 15 days after enzyme-documented AMI, 115 patients lacked typical ischemic-type chest in on presentation (the "nonpainful" group). After 25 months' mean follow-up, cardiac mortality was 20% for nonpainful patients and 10% for 2,349 patients with typical pain (the "painful" group), P < 0.001. Similar increments were seen in total deaths (27% nonpainful versus 13% painful, P < 0.001) and cardiac events, namely, cardiac death or nonfatal reinfarction (24% nonpainful versus 17% painful, P = 0.001). Late congestive heart failure was more frequent (17% nonpainful versus 7% painful, P < 0.001), but unstable angina was less (6% nonpainful versus 16% painful, P = 0.005). At outset, nonpainful patients had more left ventricular dysfunction and diabetes mellitus. However, nonpainful AMI predicted worse outcome even when these problems were absent. Logistic regression confirmed greater cardiac death risk in the nonpainful group (hazard ratio = 2.05) and showed that predictive power of nonpainful status was independent of baseline ejection fraction, Holter data, concomitant diabetes mellitus, and other covariates.
Patients hospitalized with nonpainful AMI are much more likely to experience late cardiac death or congestive heart failure than are patients with painful AMI. In part, this probably reflects more ventricular damage with alternative warning symptoms such as dyspnea. However, our data suggest that defective perception of warning pain also provides a long-term risk to life that is independent of previously known predictors of poor outcome.
虽然缺血性胸痛通常提示急性心肌梗死（AMI），但有些患者虽患AMI却无此症状而住院。此前尚未对以其他警示症状表现的AMI患者的长期死亡率和发病率进行过研究。因此，我们评估了AMI住院患者中无典型胸痛以及其他公认的风险预测因素的预后意义。
数据来自多中心地尔硫䓬梗死后试验。研究协调员根据简单的、预先设定的标准前瞻性地确定疼痛状况和其他基线特征。然后每3至4个月对患者进行检查，直至试验结束。我们应用卡方检验、生命表分析和多变量分析来评估与每个基线变量相关的预后能力的强度和独立性。
在酶学证实AMI后3至15天入组的2464例患者中，115例患者就诊时无典型缺血性胸痛（“无疼痛”组）。平均随访25个月后，无疼痛患者的心脏死亡率为20%，2349例有典型疼痛患者（“有疼痛”组）为10%，P<0.001。总死亡（无疼痛组27%，有疼痛组13%，P<0.001）和心脏事件，即心脏死亡或非致命性再梗死（无疼痛组24%，有疼痛组17%，P = 0.001）也有类似程度的增加。晚期充血性心力衰竭更常见（无疼痛组17%，有疼痛组7%，P<0.001），但不稳定型心绞痛较少（无疼痛组6%，有疼痛组16%，P = 0.005）。一开始，无疼痛患者有更多的左心室功能障碍和糖尿病。然而，即使不存在这些问题，无疼痛性AMI也预示着更差的预后。逻辑回归证实无疼痛组心脏死亡风险更高（风险比=2.05），并表明无疼痛状态的预测能力独立于基线射血分数、动态心电图数据、合并糖尿病及其他协变量。
与有疼痛性AMI患者相比，无疼痛性AMI住院患者更易发生晚期心脏死亡或充血性心力衰竭。部分原因可能是更多的心室损害伴有诸如呼吸困难等其他警示症状。然而，我们的数据表明，对警示性疼痛的感知缺陷也会带来独立于先前已知的不良预后预测因素的长期生命风险。
