Please wait a minute...
Shopping Cart Email List Chinese
Advanced Search Fig/Tab
Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Featured Articles  |  Most Downloaded  |  Most Reading
Online Submission Subscribe to Our RSS Content Feed
Front. Med.    2022, Vol. 16 Issue (4) : 651-658    https://doi.org/10.1007/s11684-021-0859-0
RESEARCH ARTICLE
Atypical manifestations of acute coronary syndrome --- throat discomfort: a multi-center observational study
Yanqing Fang1,2, Xiaoting Cheng1,2, Wenhui Peng3, Xueying Chen4(), Chunping Tang5, Qiusheng Huang6, Sihai Wu7, Yibo Huang1,2, Fanglu Chi1,2, Matthew R. Naunheim8, Huawei Li1,2, Bing Chen1,2(), Yilai Shu1,2()
1. ENT Institute and Department of Otorhinolaryngology, Eye & ENT Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200031, China; Institutes of Biomedical Sciences, Fudan University, Shanghai 200031, China
2. NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai 200031, China
3. Department of Cardiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai 200072, China
4. Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai 200032, China
5. Department of Cardiology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
6. Department of Otolaryngology, Affiliated Hospital of Jiangsu University, Zhenjiang 212001, China
7. Department of Otorhinolarynogology, The Second People’s Hospital of Wuxi, Nanjing Medical University, Wuxi 214002, China
8. Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
 Download: PDF(126 KB)   HTML
 Export: BibTeX | EndNote | Reference Manager | ProCite | RefWorks
Abstract

To present the clinical characteristics and the misdiagnosis rate of acute coronary syndrome manifested primarily as throat discomfort, we conducted a multicentric and retrospective study in the cardiology and otorhinolaryngology departments. Records of patients with primary complaint of throat discomfort, absence of chest pain at onset, and an ultimate diagnosis of acute coronary syndrome, as well as patients with pharyngitis (as controls) were collected from May 2015 to April 2016. The patients’ main manifestations were compared. Logistic regression results showed that chest tightness, dyspnea, perspiring, and exertional throat symptoms were significantly associated with acute coronary syndrome, with odds ratios of 8.3 (95% CI 2.2–31.5), 10.9 (95% CI 1.8–66.9), 25.4 (95% CI 3.6–179.9), and 81.2 (95% CI 13.0–506.7). A total of 25 (56.82%) out of 44 acute coronary syndrome patients, who were first admitted to the otorhinolaryngology department, were misdiagnosed, with a 12% (3/25) mortality rate. Throat discomfort can be the principal manifestation of acute coronary syndrome. Such patients exhibit high misdiagnosis and mortality rates. Exertional throat symptoms, chest tightness, perspiring, and dyspnea were important indicators of acute coronary syndrome in patients whose main complaint was throat discomfort. The awareness of this condition will result in prompt diagnosis and reduce morbidity and mortality.
Keywords acute coronary syndrome (ACS)      throat discomfort (TD)      throat pain      cardiology departments      non-cardiologic physicians     
Corresponding Author(s): Xueying Chen,Bing Chen,Yilai Shu   
About author:

Tongcan Cui and Yizhe Hou contributed equally to this work.
Just Accepted Date: 13 August 2021   Online First Date: 19 January 2022    Issue Date: 02 September 2022
 Cite this article:   
Yanqing Fang,Xiaoting Cheng,Wenhui Peng, et al. Atypical manifestations of acute coronary syndrome --- throat discomfort: a multi-center observational study[J]. Front. Med., 2022, 16(4): 651-658.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-021-0859-0
https://academic.hep.com.cn/fmd/EN/Y2022/V16/I4/651
Demographic information ACS-TD group (n = 101) TD group (n = 101) P value
Age (year, mean±SD) 58.1±10.1 55.9±9.3 0.121
Gender Female 38 41 0.665
Male 63 60
Past medical history Hypertension 68 (67.32%) 22 (21.78%) <0.001
Smoking 31 (30.69%) 21 (20.79%) 0.108
Diabetes 17 (16.83%) 8 (7.92%) 0.054
Prior cardiovascular diseasec 10 (9.90%) 7 (6.93%) 0.447
History of pharyngitis 9.90% (10/101) 32.67% (33/101) <0.001
Tab.1  Demographic information and past medical history of patients in ACS-TDa group and TDb group with the P value
Detailed information on throat symptoms ACS-TD group (n = 101) TD group (n = 101) P value
Throat symptoms Throat pain 48 (47.52%) 46 (45.54%) 0.778
Throat distress 32 (31.68%) 9 (8.91%) <0.001
Throat tightness (or constricting) 17 (16.83%) 5 (4.95%) 0.007
Compressing of throat
(i.e., obstruction, or choking)		 9 (8.91%) 0 (0.00%) 0.002
Foreign body sensation 0 (0.00%) 34 (33.66%) <0.001
Throat itch 1 (0.99%) 12 (11.88%) 0.002
Dry throat 0 (0.00%) 13 (12.87%) <0.001
Sense of phlegm 0 (0.00%) 8 (7.92%) 0.004
Throat burning 0 (0.00%) 1 (0.99%) 0.316
Tab.2  Detailed information on throat symptoms between ACS-TDa group and TDb group (number of patients (%))
Cardiac symptoms and past medical history information ACS-TD group (n = 101) TD group (n = 101) P value
Cardiac symptoms Chest tightness 47 (46.53%) 5 (4.95%) <0.001
Dyspnea 14 (13.86%) 5 (4.95%) 0.030
Perspiring 34 (33.66%) 2 (1.98%) <0.001
Rare symptomsc 8 (7.92%) 1 (0.99%) 0.017
History of chest pain 3 (2.97%) 3 (2.97%) 1.00
No cardiac symptoms 25 (24.75%) 90 (89.10%) <0.001
Tab.3  Information about the cardiac symptoms of ACS-TDa group and TDb group and P values (number of patients (%))
Variables Coefficientsa SEb P value ORc 95% CI
Constant value −1.875 2.190 0.392 0.15 −
Gender 0.681 0.619 0.271 1.98 0.59−6.64
Age 0.021 0.033 0.516 1.02 0.96−1.09
Chest tightness 2.111 0.683 0.002 8.26 2.16−31.52
Dyspnea 2.395 0.923 0.009 10.97 1.80−66.90
Perspiring 3.235 0.999 0.001 25.40 3.59−179.91
Exertional throat symptoms 4.397 0.934 <0.001 81.17 13.00−506.71
Severity of throat symptoms 0.047 0.384 0.902 1.05 0.49−2.23
Usefulness of medicine for pharyngitis −3.016 0.602 <0.001 0.05 0.02−0.16
Tab.4  Odds ratio of the associations between main symptoms and ACS
Unreferred patients (n = 25) 19 cases referred from ENT department and 57 cases first admitted to cardiology department (n = 76) P value
Age (year, mean±SD) 55.24±8.54 59.00±10.46 0.107
Gender Female 8 (32.00%) 30 (39.47%) 0.503
Male 17 (68.00%) 46 (60.53%)
Throat symptoms Throat pain 20 (80.00%) 28 (36.84%) <0.001
Throat distress 0 (0.00%) 32 (42.11%) <0.001
Throat tightness (or constricting) 5 (20.00%) 12 (15.79%) 0.625
Compressing of throat (i.e., obstruction or choking) 2 (8.00%) 7 (9.21%) 0.854
Foreign body sensation 0 (0.00%) 0 (0.00%) 1.00
Throat itch 0 (0.00%) 1 (1.325) 0.654
Dry throat 0 (0.00%) 0 (0.00%) 1.00
Sense of phlegm 0 (0.00%) 0 (0.00%) 1.00
Throat burning 0 (0.00%) 0 (0.00%) 1.00
Cardiac symptoms Chest tightness 9 (36.00%) 38 (50.00%) 0.223
Dyspnea 4 (16.00%) 10 (13.16%) 0.721
Perspiring 10 (40.00%) 24 (31.58%) 0.440
Rare symptomsb 2 (8.00%) 6 (7.89%) 0.987
History of chest pain 0 (0.00%) 3 (3.95%) 0.313
No cardiac symptoms 6 (24.00%) 19 (25.00%) 0.920
Past medical history Hypertension 16 (64.00%) 52 (68.42%) 0.683
Smoking 5 (20.00%) 26 (34.21%) 0.181
Diabetes 3 (12.00%) 14 (18.42%) 0.457
Prior cardiovascular diseasec 0 (0.00%) 10 (13.16%) 0.056
History of pharyngitis 8 (32.00%) 2 (2.63%) <0.001
Tab.5  Detailed information of comparison between the unreferred and the other patients including 19 cases referred from the ENT department and 57 cases first admitted to cardiology of ACS-TDa patients (number of patients (%))
1 P Joseph, D Leong, M McKee, SS Anand, JD Schwalm, K Teo, A Mente, S Yusuf. Reducing the global burden of cardiovascular disease, part 1: the epidemiology and risk factors. Circ Res 2017; 121(6): 677–694
https://doi.org/10.1161/CIRCRESAHA.117.308903 pmid: 28860318
2 GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990−2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388(10053): 1603–1658
https://doi.org/10.1016/S0140-6736(16)31460-X pmid: 27733283
3 ED Grech, DR Ramsdale. Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction. BMJ 2003; 326(7401): 1259–1261
https://doi.org/10.1136/bmj.326.7401.1259 pmid: 12791748
4 CJ Ryan, HA DeVon, JJ Zerwic. Typical and atypical symptoms: diagnosing acute coronary syndromes accurately. Am J Nurs 2005; 105(2): 34–36
https://doi.org/10.1097/00000446-200502000-00023 pmid: 15674053
5 PW Li, DS Yu. Predictors of pre-hospital delay in Hong Kong Chinese patients with acute myocardial infarction. Eur J Cardiovasc Nurs 2018; 17(1): 75–84 doi: 10.1177/1474515117718914 PMID: 28657336
6 A El-Menyar, M Zubaid, K Sulaiman, W AlMahmeed, R Singh, AA Alsheikh-Ali, J; Gulf Registry of Acute Coronary Events (Gulf RACE) Investigators Al Suwaidi. Atypical presentation of acute coronary syndrome: a significant independent predictor of in-hospital mortality. J Cardiol 2011; 57(2): 165–171
https://doi.org/10.1016/j.jjcc.2010.11.008 pmid: 21242059
7 HA Khafaji, JM Suwaidi. Atypical presentation of acute and chronic coronary artery disease in diabetics. World J Cardiol 2014; 6(8): 802–813
https://doi.org/10.4330/wjc.v6.i8.802 pmid: 25228959
8 JG Canto, MG Shlipak, WJ Rogers, JA Malmgren, PD Frederick, CT Lambrew, JP Ornato, HV Barron, CI Kiefe. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000; 283(24): 3223–3229
https://doi.org/10.1001/jama.283.24.3223 pmid: 10866870
9 WB Kannel, RD Abbott. Incidence and prognosis of unrecognized myocardial infarction. An update on the Framingham study. N Engl J Med 1984; 311(18): 1144–1147
https://doi.org/10.1056/NEJM198411013111802 pmid: 6482932
10 Y Yanagawa, M Nishimura, J Ohkawara, K Hasegawa, M Yamane. Acute myocardial infarction presenting with pharyngeal pain alone. J Emerg Med 2012; 43(5): e287–e288
https://doi.org/10.1016/j.jemermed.2010.05.028 pmid: 20634021
11 M Sone, A Koizumi, E Tamiya, K Inoue, I Ebihara, H Koide, S Okazaki, Y Kato, J Suzuki, H Daida. Angina pectoris with pharyngeal pain alone: a case report. Angiology 2009; 60(2): 259–261
https://doi.org/10.1177/0003319707311537 pmid: 18388102
12 U Ocak, L Avsarogullari, MG Kaya, Y Ozmen, B Taslidere, EA Guldeste, S Yakar. Acute coronary syndrome presenting with earache and sore throat. Am J Emerg Med 2014; 32(5): 48. e5-6
13 S Amirhaeri, D Spencer. Myocardial infarction with unusual presentation of otalgia: a case report. Int J Emerg Med 2010; 3(4): 459–460
https://doi.org/10.1007/s12245-010-0222-8 pmid: 21373323
14 ST Shulman, AL Bisno, HW Clegg, MA Gerber, EL Kaplan, G Lee, JM Martin, C; Infectious Diseases Society of America Van Beneden. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55(10): e86–e102
https://doi.org/10.1093/cid/cis629 pmid: 22965026
15 E Chiappini, M Regoli, F Bonsignori, S Sollai, A Parretti, L Galli, M de Martino. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther 2011; 33(1): 48–58
https://doi.org/10.1016/j.clinthera.2011.02.001 pmid: 21397773
16 RC Serlin, TR Mendoza, Y Nakamura, KR Edwards, CS Cleeland. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995; 61(2): 277–284
https://doi.org/10.1016/0304-3959(94)00178-H pmid: 7659438
17 B Ibánez, S James, S Agewall, MJ Antunes, C Bucciarelli-Ducci, H Bueno, ALP Caforio, F Crea, JA Goudevenos, S Halvorsen, G Hindricks, A Kastrati, MJ Lenzen, E Prescott, M Roffi, M Valgimigli, C Varenhorst, P Vranckx, P Widimský. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Rev Esp Cardiol (Engl Ed) 2017; 70(12): 1082
https://doi.org/10.1016/j.rec.2017.11.010 pmid: 29198432
18 M Roffi, C Patrono, JP Collet, C Mueller, M Valgimigli, F Andreotti, JJ Bax, MA Borger, C Brotons, DP Chew, B Gencer, G Hasenfuss, K Kjeldsen, P Lancellotti, U Landmesser, J Mehilli, D Mukherjee, RF Storey, S; ESC Scientific Document Group Windecker. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37(3): 267–315
https://doi.org/10.1093/eurheartj/ehv320 pmid: 26320110
19 GW Reed, JE Rossi, CP Cannon. Acute myocardial infarction. Lancet 2017; 389(10065): 197–210
https://doi.org/10.1016/S0140-6736(16)30677-8 pmid: 27502078
20 JS Meza. Mortality caused by acute myocardial infarction in Chile in the period 1990–2001. Rev Med Chil 2004; 132(10): 1227–1233 (in Spanish)
pmid: 15631212
21 AN Mahmoud, IY Elgendy, MK Mojadidi, SA Wayangankar, AA Bavry, RD Anderson, H Jneid, CJ Pepine. Prevalence, causes, and predictors of 30-day readmissions following hospitalization with acute myocardial infarction complicated by cardiogenic shock: findings from the 2013–2014 national readmissions database. J Am Heart Assoc 2018; 7(6): e008235
https://doi.org/10.1161/JAHA.117.008235 pmid: 29572325
22 JH Pope, TP Aufderheide, R Ruthazer, RH Woolard, JA Feldman, JR Beshansky, JL Griffith, HP Selker. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342(16): 1163–1170
https://doi.org/10.1056/NEJM200004203421603 pmid: 10770981
23 M Kreiner, JP Okeson, V Michelis, M Lujambio, A Isberg. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. J Am Dent Assoc 2007; 138(1): 74–79
https://doi.org/10.14219/jada.archive.2007.0024 pmid: 17197405
24 DE Myers. Vagus nerve pain referred to the craniofacial region. A case report and literature review with implications for referred cardiac pain. Br Dent J 2008; 204(4): 187–189
https://doi.org/10.1038/bdj.2008.101 pmid: 18297020
25 EB Schelbert, JS Rumsfeld, HM Krumholz, JG Canto, DJ Magid, FA Masoudi, KJ Reid, JA Spertus. Ischaemic symptoms, quality of care and mortality during myocardial infarction. Heart 2008; 94(2): e2
https://doi.org/10.1136/hrt.2006.111674 pmid: 17639097
26 KA Milner, M Funk, A Arnold, V Vaccarino. Typical symptoms are predictive of acute coronary syndromes in women. Am Heart J 2002; 143(2): 283–288
https://doi.org/10.1067/mhj.2002.119759 pmid: 11835032
27 S Mirzaei, A Steffen, K Vuckovic, C Ryan, U Bronas, J Zegre-Hemsey, HA DeVon. The quality of symptoms in women and men presenting to the emergency department with suspected acute coronary syndrome. J Emerg Nurs 2019; 45(4): 357–365
https://doi.org/10.1016/j.jen.2019.01.001 pmid: 30738603
28 M Kreiner, D Falace, V Michelis, JP Okeson, A Isberg. Quality difference in craniofacial pain of cardiac vs. dental origin. J Dent Res 2010; 89(9): 965–969
https://doi.org/10.1177/0022034510370820 pmid: 20448243
29 M Kreiner, R Alvarez, A Waldenström, V Michelis, R Muñiz, A Isberg. Craniofacial pain of cardiac origin is associated with inferior wall ischemia. J Oral Facial Pain Headache 2014; 28(4): 317–321
https://doi.org/10.11607/ofph.1257 pmid: 25347166
Viewed
Full text


Abstract

Cited
  Shared   
  Discussed