European Heart Journal Advance Access originally published online on October 4, 2006
European Heart Journal 2006 27(21):2607; doi:10.1093/eurheartj/ehl286
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Atypical presentation and unrecognized myocardial infarction
uli
Department of Medicine
Division of Cardiology
University Hospital Split
Spinciceva 1
Split 21000
Croatia
Tel: +385 21 538 251
Fax: +385 21 556 031
E-mail address: viktor.culic{at}st.t-com.hr
de Torbal et al.1 reported on the incidence of recognized and unrecognized myocardial infarction in patients aged 55 and older. I would like to draw attention to the previous work of our group that may help explaining several findings of this study. A high incidence of unrecognized myocardial infarction relative to other investigations may be due to an independent tendency towards ‘atypical’ clinical presentation of the infarction onset with increasing age.2,3 Such an atypical presentation includes the absence of chest pain and the presence of non-chest pain, particularly localized in the neck, back, jaw, or head, followed by non-pain symptoms such as weakness, sweating, nausea, dyspnoea, or cough. Women seem to be another subgroup with a greater likelihood of atypical presentation pattern2 which agrees with a greater presence of unrecognized infarctions among them compared with men reported by de Torbal et al.1
The symptomatology of myocardial infarction, including both pain and non-pain symptoms, may be affected by traditional risk factors, such as smoking, hypertension, diabetes, and hypercholesterolaemia.2 The extent of infarcted myocardium, probably through a number of stimulated nerve afferents, may also influence the symptom presentation.2,4 This may be related to a lower frequency of chest pain among those evolving non-Q than among those evolving Q-wave infarction.2 Finally, isolated infarctions of inferior or lateral site more often have atypical presentation compared with anterior infarctions.3 Unfortunately, de Torbal et al.1 did not report on ECG characteristics (type and site) of unrecognized myocardial infarctions. In further investigations dealing with the incidence of unrecognized myocardial infarction, information on mental and neurological disorders, psychotropic drugs, alcohol consumption, and religiousness should also be considered because they could change the perception of pain and other symptoms.
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 recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study. Eur Heart J 27:729–736.
[Abstract/Free Full Text] - uli V, Eterovi D, Miri D, Sili N. (2002) Symptom presentation of acute myocardial infarction: influence of gender, age and risk factors. Am Heart J 144:1012–1017.[CrossRef][ISI][Medline]
- uli V, Miri D, Eterovi D. (2001) Correlation between symptomatology and site of acute myocardial infarction. Int J Cardiol 77:163–168.[CrossRef][ISI][Medline]
- uli V, Miri D, Eterovi D. (2002) Different circumstances, timing, and symptom presentation at onset of Q wave versus non-Q wave acute myocardial infarction. Am J Cardiol 89:456–460.[CrossRef][ISI][Medline]
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