European Heart Journal Advance Access originally published online on April 7, 2006
European Heart Journal 2006 27(11):1383-1384; doi:10.1093/eurheartj/ehi864
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Incidence of recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study
Medical Division
Manchester Medical Society
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The Rotterdam Study1 might well be a ‘wake-up call’ for those authors of management guidelines for myocardial infarction (MI), who do not sufficiently stress the potential for saving lives if the non-chest pain presentations of MI are promptly recognized and evaluated for eligibility for thrombolysis and other therapeutic strategies. Our National Service Framework (NSF) for coronary heart disease recognizes that many patients initially thought to have MI may have other causes for their chest pain. Nevertheless, it does not stress that, as a corollary, MI might have a pain-free presentation characterized, instead, by sudden onset of unexplained dyspnoea and by unexplained collapse.2 These alternative clinical stigmata of MI are well described in the elderly,3 and might well have been a feature of many of the patients in the Rotterdam Study. The other major shortcoming of our NSF emerges in the outline of models of care to be used in hospital-wide protocols, and here the advice on the assessment of eligibility for thrombolysis deals with management of those MI patients who present with chest pain without referring to the potential benefits of thrombolysis in those who do not have chest pain.2 Nowhere is there a recognition that a pain-free MI patient who presents to the hospital promptly with sudden onset dyspnoea or collapse might well be within the therapeutic time window for thrombolysis if the electrocardiographic criteria for such treatment are met.4
References
- de Torbal A, Boersma E, Kors JA, van Herpen G, Deckers JW, van der Kuip DAM, Stricker BH, Hofman A, Witteman JCM. (2006) Incidence of recognised and unrecognised myocardial infarction in men and women aged 55 and older: the Rotterdam Study. Eur Heart J 27:729–736.
[Abstract/Free Full Text] - Doyle P, Gwynn H, Hicks N, Hunt J, Martin D, McKessack J, Paine D, Phlillips C, Quinn T. all on behalf of the Department of Health. (2000) Heart attacks and other acute coronary syndromes. National Service Frameworks for Coronary Heart Disease (Department of Health, London) pp. 1–51 Chap. 3.
- Bayer AG, Chandra JS, Farag RR, Pathy MSJ. (1986) Changing presentation of myocardial infarction with increasing age. J Am Geriatrics Soc 34:263–266.[ISI][Medline]
- Jolobe OMP. (1994) Presentation is often pain-free in elderly patients. (Letter). BMJ 308:1159.
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