Atypical presentations of myocardial infarction in patients with diabetes mellitus: diagnostic challenges and clinical outcomes; a systematic review
DOI:
https://doi.org/10.65759/ggz33t49Keywords:
Diabetes mellitus, myocardial infarction, atypical presentation, chest pain, diagnostic delayAbstract
Background: Diabetes mellitus complicates recognition of myocardial infarction through heterogeneous symptoms, comorbid illness, and delayed presentation. The relationship between diabetes and absence of chest pain differs between populations. This review examined presenting symptoms, diagnostic challenges, and associated clinical outcomes. Methods: we include ten articles, covering symptom comparisons, care seeking, diagnostic recognition, and prognosis. Eligible studies concerned adults with myocardial infarction or relevant acute coronary syndrome populations and publication through May 2026. Quantitative associations and qualitative findings were examined separately without statistical pooling. Results: Large registries associated diabetes with presentation without chest pain, although Swedish investigations reported similar frequencies of typical symptoms after adjustment. Breathlessness and fatigue featured prominently in several cohorts, with inconsistent differences across individual symptoms. A Swedish multicentre study reported median delays to first medical contact of 144 minutes with diabetes and 75 minutes without diabetes. In the Korean registry, two-year mortality among patients with diabetes was 29.5% with atypical presentation versus 11.4% with typical presentation. Broader coronary syndrome cohorts linked absent chest pain to missed initial recognition and less frequent evidence-based treatment. Definitions, adjustment strategies, overlapping registry populations, and observational designs limited causal interpretation. Conclusion: Diabetes-associated myocardial infarction presents in a broad symptom spectrum. Chest pain remains common, while its absence identifies a diagnostic vulnerability. Fast electrocardiography, contextual troponin interpretation, and symptom education warrant clinical attention.
References
1. Emerging Risk Factors Collaboration; Sarwar N, Gao P, Seshasai SRK, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215–2222.
2. Rawshani A, Rawshani A, Franzén S, et al. Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2018;379(7):633–644.
3. Pop-Busui R, Evans GW, Gerstein HC, et al. Effects of cardiac autonomic dysfunction on mortality risk in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Diabetes Care. 2010;33(7):1578–1584.
4. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018;72(18):2231–2264.
5. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;144(22):e368–e454.
6. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163–1170.
7. Diercks DB, Kirk JD, Lindsell CJ, et al. Door-to-ECG time in patients with chest pain presenting to the ED. Am J Emerg Med. 2006;24(1):1–7.
8. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283(24):3223–3229.
9. Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126(2):461–469.
10. DeVon HA, Penckofer S, Larimer K. The association of diabetes and older age with the absence of chest pain during acute coronary syndromes. West J Nurs Res. 2008;30(1):130–144.
11. Ängerud KH, Brulin C, Näslund U, Eliasson M. Patients with diabetes are not more likely to have atypical symptoms when seeking care of a first myocardial infarction. An analysis of 4028 patients in the Northern Sweden MONICA Study. Diabet Med. 2012;29(7):e82–e87.
12. Ängerud KH, Brulin C, Näslund U, Eliasson M. Longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the Northern Sweden MONICA Study. BMC Cardiovasc Disord. 2013;13:6.
13. Ängerud KH, Brulin C, Eliasson M, Näslund U, Hörnsten Å. The process of care-seeking for myocardial infarction among patients with diabetes. J Cardiovasc Nurs. 2015;30(5):E1–E8.
14. Ängerud KH, Thylén I, Sederholm Lawesson S, Eliasson M, Näslund U, Brulin C. Symptoms and delay times during myocardial infarction in 694 patients with and without diabetes; an explorative cross-sectional study. BMC Cardiovasc Disord. 2016;16:108.
15. Fu R, Li SD, Song CX, et al. Clinical significance of diabetes on symptom and patient delay among patients with acute myocardial infarction—an analysis from China Acute Myocardial Infarction (CAMI) registry. J Geriatr Cardiol. 2019;16(5):395–400.
16. Lee JW, Moon JS, Kang DR, et al. Clinical impact of atypical chest pain and diabetes mellitus in patients with acute myocardial infarction from prospective KAMIR-NIH registry. J Clin Med. 2020;9(2):505.
17. Schmitz T, Wein B, Raake P, et al. Do patients with diabetes with new onset acute myocardial infarction present with different symptoms than non-diabetic patients? Front Cardiovasc Med. 2024;11:1324451.
18. Wereski R, Kimenai DM, Taggart C, et al. Cardiac troponin thresholds and kinetics to differentiate myocardial injury and myocardial infarction. Circulation. 2021;144(7):528–538.
19. Neumann JT, Twerenbold R, Ojeda F, et al. Application of high-sensitivity troponin in suspected myocardial infarction. N Engl J Med. 2019;380:2529–2540.
20. Wackers FJTh, Young LH, Inzucchi SE, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care. 2004;27(8):1954–1961.
21. Young LH, Wackers FJTh, Chyun DA, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. JAMA. 2009;301(15):1547–1555.
22. Dracup K, McKinley S, Riegel B, et al. A randomized clinical trial to reduce patient prehospital delay to treatment in acute coronary syndrome. Circ Cardiovasc Qual Outcomes. 2009;2(6):524–532.
