Comparison of Clinical presentation of Acute Coronary Syndrome in Diabetic Vs Non-diabetic patients

 

Dhanya A, Praveen Agarwal, Manju Dhandapani, Jaideep Mahendra, Lakshmanan Gopichandran

¹College of Nursing, AIIMS, New Delhi

²Professor, Dept. of  Emergency Medicine, AIIMS, New Delhi

³Lecturer, PGIMER, Chandigarh

⁴Jaideep Mahendra, Professor, Meenakshi Ammal Dental College, Chennai

⁵Lecturer, College of Nursing, AIIMS, NewDelhi

 

ABSTRACT:

Background: Diabetes mellitus (DM) is one of the major risk factors of acute coronary syndrome (ACS). There are certain differences reported in clinical presentation of patients with ACS between diabetic and non-diabetic patients. Objective: To compare the clinical profile and symptoms experienced by diabetic and non-diabetic patients of ACS. Methodology: A descriptive cross-sectional survey was conducted among 60 diabetic and 60 non-diabetic patients hospitalized with ACS in atertiary care centre, Delhi. The sample size of 120 i.e. 60 in each diabetic and non- diabetic group, was statistically calculated. Patients were enrolled only if they were hemodynamically stable and did not have any cognitive dysfunction or communication disability. Consent was obtained from patients after explaining the objectives of the study. Data on patient as well as clinical profile and initial symptoms of ACS were collected using structured interview. Results: The mean age of the patients with DM was 64.23+14.7years and without DM was 64+13.1years. Majority of the patients in both groups were males, married, belonged to nuclear family and were from urban setting. When 56.67% of diabetic patients were employed, 63% of non-diabetic patients were retired (p=0.001). Two third of the patients were diagnosed to be diabetic for more than one year. Majority of the patients who were on treatment were receiving oral hypoglycemic agents. As compared to non-diabetic patients of ACS, more number of diabetic patients with ACS were found to have high cholesterol level, alcoholism, family history of CAD, previous history of ACS, history of CABG and endovascular coronary interventions. Significantly higher number of diabetic patients i.e,83.3% were found to have STEMI as compared to 38.3% in non-diabetic patients. Cardiac enzymes were elevated in 90% of the diabetic patients as compared to 55% of non-diabetic patients (p=0.001). When 86.7% of non-diabetic patients experienced chest pain as one of the initial symptom of ACS, only 20% diabetic patients experienced the same in non-diabetic patients(p=0.001). Among prevalent symptom of ACS, chest pain, cold sweat, nausea/vomiting and palpitation were reported by significantly higher number of non-diabetic patients.  significantly higher number of diabetic patients reported shortness of breath/ dyspnea, gastric discomfort, unusual fatigue, anxiety, syncope/giddiness and headache. While, significantly more number of non-diabetic patients reported pain in shoulders and arms. Significantly more number of diabetic patients reported jaw pain and neck pain. Conclusion: As per the present study findings, chest pain is less prevalent as an initial symptom of ACS in patients of diabetes and the diabetic patients may experience various atypical symptoms other than chest pain during ACS. Dyspnea, syncope/ giddiness were the major symptoms experienced by diabetic patients during ACS as compared to non-diabetic patients. Appropriate measures must be taken for diabetic patients by the health care providers to facilitate early and adequate management of ACS.

 

 

 

 

 

 

INTRODUCTION:

Cardiovascular diseases (CVDs) are the leading causes of death globally. It is predicted that about 25 million people may die by 2030 because of CVDs^1,2. Diabetes mellitus (DM) is one of the modifiable risk factors of cardiovascular diseases, especially coronary artery disease^1,2. Reports from World Health Organization (WHO) and International Diabetes federation (IDF) shows that 32 million people had diabetes in the year 2000 and it is estimated that around 40.9 million people in India has diabetes. It may further rise to 69.9 million by 2025². Incidence of painless acute coronary syndrome (ACS) is reported to be higher in patients of DM and can result delay in treatment³.

 

It is believed that there are certain difference in clinical presentation of patients with ACS between diabetic and non-diabetic patients. Chest pain is the predominant symptom of ACS which helps in early identification and most commonly used criteria to establish the effectiveness of treatment. Although symptomatic ST changes are recorded in ECG, many individuals with severe coronary artery lesions may not perceive angina pectoris. Other than chest pain, patients with ACS also can present with atypical symptoms such as mild back pain, unusual fatigue, nausea, vomiting, dyspnea, syncope, palpitations, numbness in hands and indigestion⁴. Due to various factors, patients with ACS may present only with atypical symptoms. Hence, transient myocardial ischemia may be silent in those patients³. And majority of the patients who do not present with the chest pain as initial symptom are at increased risk of delayed medical attention and receive less aggressive treatment which may lead to highest hospital mortality^4-6.

 

Diabetes is a major factor that influence the symptomatology of patients with ACS, especially in elderly due to their comorbidities^3,7,8. Diabetes is reported to be an independent predictor of atypical presentation of acute myocardial infarction⁹. Silent myocardial infarction/ischemia is becoming more prevalent, may be due to the increased prevalence of various factors contributing to it or could be due to prompt investigative strategies to identify the same¹⁰. Up to 25% of patients with coronary artery disease (CAD) have suffered silent MI and is reported to be more prevalent in diabetics.

 

Though the exact mechanism of silent MI is still unclear, the presence of cardiac autonomic dysfunction is the assumed factor that influences the frequency of SMI in diabetics. As per literature, due to reduced autonomic function and neuropathy, patients of diabetes may not be able to perceive the actual severity of the chest pain^3,9. Apart from differences in cardiac symptoms, patients with diabetes report less nausea, squeezing aching type pain and more hyperventilation ³. Diabetic patients with ST elevation MI may not have difference in cardiac symptoms but may have associated symptoms¹¹.

 

Literature shows that symptom presentation in ACS are also influenced by many other factors such as age, gender difference, types of risk factors and other comorbidities present in the patients. Old age patients are less likely to perceive chest pain radiating to arm and shoulder but present with the complaints of abdominal discomfort, nausea and/ or vomiting¹². Though, risk of not perceiving chest pain is equal in both the gender, prevalence of atypical symptoms is more in females¹³. Male patients may present with atypical symptoms such as mid back pain, nausea and/or vomiting, dyspnea, palpitations and indigestion, whereas female patients present with nausea, vomiting, numbness in hands, unusual fatigue and indigestion^8,14.As compared to males, less females report chest pain as chief complaint⁹. But conflicting results exist where both the genders are equally expected to present without chest pain¹⁴. Few evidences from the literature show that there is no difference in the prevalence as well as severity of chest pain or atypical presentation of ACS in both diabetic and non-diabetic patients^11,12,15. Hence present study was under taken to compare the clinical profile and clinical presentation of patients with ACS in both diabetic and non-diabetic patients.

 

METHODS:

A comparative cross-sectional design was used to analyze the differences in symptom perception in diabetic and non diabetic patients diagnosed with ACS.  Adult patients diagnosed and admitted with ACS in a tertiary care center, Delhi were enrolled using non-probability consecutive sampling technique. The sample size of 120 ie, 60 in each diabetic and non- diabetic group, was statistically calculated. Patients were enrolled only if they were hemodynamically stable and did not have any cognitive dysfunction or communication disability. Patients who had New York Heart Association (NYHA) grade III and IV heart failure and mechanically ventilated patients were excluded from the study. Consent was obtained from patients after explaining the objectives of the study. The subjects were ensured of confidentiality of information provided by them. Written permission for conducting the research study from the Head of the Cardiology Department and ethical clearance was obtained from Institute Ethics Committee.

 

Tools of data collection:

A structured interview schedule was developed based on the reviews from various studies. Validity was established by the researcher (α= 0.861). Pilot study was conducted on 10 patients diagnosed with ACS and the tool was found to be feasible. Patients with ACS who met the inclusion criteria were enrolled after taking informed written consent. Data was collected from hemodynamically stable patients who were pain free at the time of data collection. Information given by the patients was verified with their relatives to enhance the authenticity. Information on clinical profile was obtained from the medical records of the patients. Blood samples were collected from the patients and sent to cardiac biochemistry laboratory for investigations (RBS, FBS, HbA1C, total cholesterol and serum triglycerides). Data analysis was done using SPSS IBM version 17 based on the objectives of the study. Chi-square test and independent sample t test was used to compare the categorical and continuous variables respectively across the group. A p value of <0.05 was considered statistically significant.

 

RESULTS:

Comparison of demographic and clinical characteristics of the ACS survivors is shown in table 1. The mean age of the patients with DM was 64.23+14.7 years and without DM was 64+13.1years. Majority of the patients in both groups were males, married, belonged to nuclear family and were from urban setting. When 56.67% of diabetic patients were employed, 63% of non-diabetic patients were retired (p=0.001).

 

Table1: Socio-demographic characteristics of patients with ACS                                                                                                        n=120

^{*p value significant at <0.05}

 

Figure 1: Comparison of risk factors between the diabetic and non-diabetic patients of ACS

 

Table 2 shows compares the diabetic profile of the patients of ACS with and without DM. Two third of the patients were diagnosed to be diabetic for more than one year. Majority of the patients who were on treatment were receiving oral hypoglycemic agents. Family history of diabetes was present in 66.7% of the patients. The mean fasting blood sugar was 155.92±42.2mg% and the mean glycosylated hemoglobin was 7.9±1.8 g%.

Figure 1 compares the risk factors of CAD present in diabetic and non-diabetic patients of ACS. Hypertension was present in 82% of the non-diabetic patients as compared to 57% of the diabetic patients. As compared to non-diabetic patients of ACS, more number of diabetic patients with ACS were found to have high cholesterol level, alcoholism, family history of CAD, previous history of ACS, history of CABG and endovascular coronary interventions.

 

Table 2: Diabetic profile of patients admitted with ACS n1=60

Variable		Frequency (%)
Duration of diabetes mellitus	<1 Year	22 (36.7)
	2years-5years	20 (33.3)
	>5years	18 (30)
Treatment	Receiving	41(68.3)
Type of treatment	OHA	38(92.7)
	Insulin	3(7.3)
Regularity of treatment	Regularly following	24 (40)
Family history of DM	Present	40 (66.7)
FBS (mg/dl)		155.92±42.2
HbA1c (%)		7.9±1.8

 

Table 3: Comparison of clinical profile (physiological and biochemical parameters) of diabetic and non-diabetic patients with ACS                                                                                                                n=120

Variable	Diabetic group (n1=60) Mean ± SD	Non-diabetic group(n2=60) Mean ± SD	P value
Pulse Rate (beats/min)	76.90±11.57	75.68±11.87	0.571
Systolic blood pressure (mm Hg)	128.3± 18.5	131±16.9	0.274
Diastolic blood pressure (mm Hg)	87.53 ± 9	87.32 ± 10.4	0.904
Total cholesterol (mg/dl)	187.6± 28.3	177.8 ± 24	0.041*
Serum triglycerides (mg/dl)	131.7 ±37.2	115.07±28	0.007*
RBS (mg/dl)	218± 66	165.3±27.9	0.001*

*p value significant at <0.05

 

Table 4: Comparison of clinical profile (cardiac enzyme, diagnosis and area of infarction) of patients admitted with ACS        n=120

Variable		Diabetic group (n1=60) Frequency (%)	Non-diabetic group (n2=60) Frequency (%)	P value
Diagnosis	STEMI	50 (83.3)	23 (38.3)	0.001*
	NSTEMI	4 (6.67)	10 (16.7)
	Unstable angina	6 (10)	27 (45)
Area of Infarction#	Anterior wall MI	20 (40)	11 (47)	0.978
	Inferior wall MI	10  (20)	9 (39)	0.107
	Lateral wall MI	17 (34)	6(26.1)	0.434
	Posterior wall MI	13 (26)	6 (26.1)	0.927
Cardiac enzymes	Elevated	54 (90)	33 (55)	0.001*
	Normal	6 (10)	27 (45)

* p value significant at <0.05                                 # here n is more than 60 as one person can have more than one area infracted

 

Table 5: Comparison of symptoms experienced by diabetic and non-diabetic patients during ACS                            n=120

* p value significant at <0.05, ^ Fischer exact test, Chi square test

 

Table6: Association of the major symptoms of diabetic patients with selected demographic, clinical and biochemical variables.    n=60

Symptom	Variable		Freq (%)	P value
Shortness of breath	Sex	Male	43 (89.6)	0.001*^
		Female	5 (10.4)
giddiness/ syncope	Hypertension	Present	22 (76)	0.004*
		Absent	7 (24)
	Alcoholism	Present	22 (76)	0.004*
		Absent	7 (24)
	Duration diabetes	≤5yr	24 (83)	0.037*
		>5yr	5 (17)

* p value significant at <0.05, Chi square, ^ Fischer exact test

 

As shown in table 3, the mean total cholesterol, serum triglyceride and random blood sugar were significantly higher in diabetic patients with ACS as compared to non-diabetic patients.

 

As shown in table 4, significantly higher number of diabetic patients i.e,83.3% were found to have STEMI as compared to 38.3% in non-diabetic patients. Near to half of the patients in both the groups had anterior wall MI. Cardiac enzymes were elevated in 90% of the diabetic patients as compared to 55% of non-diabetic patients (p=0.001).

 

Comparison of symptoms perceived at the onset by diabetic and non-diabetic patients of ACS is shown in table 5.  When 86.7% of non-diabetic patients experienced chest pain as one of the symptom at onset of ACS, only 20% diabetic patients experienced the same (p=0.001). Significantly higher number of diabetic patients reported shortness of breath/ dyspnea, gastric discomfort,unusual fatigue, anxiety, syncope/giddiness and headache.While, significantly more number of non-diabetic patients reported pain in shoulders and arms, significantly more number of diabetic patients reported jaw pain and neck pain.

 

Significantly higher number of non-diabetic patients (80%) experienced cold sweat/ sweating, whereas only 18.3% of diabetic patients experienced the same (p=0.001). Nausea/vomiting was reported by 58.3% of non-diabetic patients, but by 8.3% of diabetic patients (p=0.001). Palpitation was experienced by 68.3% of the diabetic patients, but only by 3.3% of the non-diabetic patients (p=0.001).

 

When shortness of breath was experienced by 80% of the diabetic patients, only 5 % of non-diabetic patients experienced the same (p=0.001). Gastric discomfort was experienced by 11.7% of the diabetic patients whereas it was not reported by any of the non-diabetic patients (p=0.013). Unusual fatigue was experienced by 36.7% of the diabetic patients, but only by 1.67% of the non-diabetic patients (p=0.001).  When 71.7% of the diabetic patients experienced anxiety, only 30% of the non-diabetic patients experienced the same (p=0.001). Syncope/ giddiness was experienced by 48.3% of diabetic patients, but only by 8.3% of non-diabetic patients (p=0.001). Head ache was experienced by 16.7% of diabetic patients whereas by none of the non-diabetic patients (p=0.001).

 

Hence, among prevalent symptom of ACS, chest pain, cold sweat, nausea/vomiting and palpitation were reported by significantly higher number of non-diabetic patients. While significantly higher number of diabetic patients reported shortness of breath/ dyspnea, gastric discomfort, unusual fatigue, anxiety, syncope/giddiness and headache.

 

Analysis on association of major symptoms with demographic and diabetic profile among diabetic patients shows that shortness of breath experienced by significantly higher number of male patients. Giddiness/ syncope was reported by significantly higher number of patients with duration of diabetes more than five years, hypertension and alcoholism (Table 6). 

 

DISCUSSION:

The clinical presentation of patients with ACS who are known cases of diabetes mellites is reported to be different from that of patients without diabetes. Present study analyzed the difference in clinical profile and clinical presentation in patients of ACS with and without diabetes.

 

Majority of both diabetic and non-diabetic patients admitted with ACS in present study were males which is a non-modifiable risk factor of CAD¹⁶. Majority of diabetic patients were employed, while majority of non-diabetic patients were retired. Mean age of diabetic patients was significantly lesser as compared to non-diabetic patients. It shows the influence of diabetes on atherosclerotic changes at early age. Though controversial, influence of antidiabetic treatment such as sulfonyl ureas on myocardial infarction is reported in the literature¹⁷. Among diabetic patients, only 60% maintained good therapeutic compliance.  Poor therapeutic compliance may impede the glycemic control and can act as another contributing factor to early occurrence of CAD resulting in ACS. Previous history of CAD, hypertension, smoking and alcoholism were the prevalent risk factors reported by both diabetic non-diabetic patients in present study¹⁶. Hypertension was more prevalent in non-diabetic patients. Patients with diabetes may develop atherosclerotic changes due to microvascular changes, while non-diabetic patients may develop the same due to increased peripheral vascular resistance. Contradictory to this finding, few previous studies have found that hypertension is more prevalent in diabetic as compared to non-diabetic patients with acute MI^15,18,19.

 

On comparison of clinical profile, it was found that the mean cholesterol and triglycerides were significantly high in diabetic patients. Significantly higher number of diabetic patients were diagnosed to have STEMI as compared to unstable angina in non-diabetic patients. However, this finding was contrasting to the previous reports where DM was common amongst patients admitted with ACS without ST elevation^19,20.When 90% of the diabetic patients in present study had elevated cardiac enzymes, only 55% of the non-diabetic patients had the same. But, Fazal  et al in 2005 had reported similar prevalence of elevated biomarkers in both diabetic and non-diabetic patients¹⁹.

 

Chest pain is the commonest symptom of ACS which was reported by most of the non-diabetic patients in present study, while the same was reported by only 20% of the diabetic patients. Similar to previous reports ^5,12,13, the prevalence of chest pain reported by diabetic patients with ACS was significantly lower when compared with non-diabetic patients. Diabetes mellites is reported in literature as one of the commonest cause of silent MI ^5,12,13. Possible explanations for the atypical symptoms in patients with diabetes mellitus, comprise central mechanisms such as altered thresholds of pain sensitivity, beta-endorphin levels, in addition to autonomic neuropathy resulting in sensory denervation⁷. Neuropathy of nerves that supplying heart and chest may mask the important symptoms of chest pain or back pain in diabetic patients and they may not feel the pain^7,21-23.

 

Findings of the present study suggested that diabetic patients did not experience much chest pain as compared to non-diabetic patients but they experienced other symptoms like dyspnea, anxiety, and syncope which is congruent with the findings of Culić V et al (2002) and who reported that diabetes is an independent predictor of non-chest pain symptoms in both men and women⁹.DeVon et.al in 2008 also reported that patients of diabetes report less squeezing and less aching type pain²². Prevalence of shortness of breath, neck/throat pain and arm/shoulder pain in patients of diabetes suffering from ACS is reported by Funk M et al in 2001¹¹. Similar to previous report²², nausea/vomiting was less prevalent in patients of diabetes in present study. According to the present study, male diabetic patients experienced more dyspnea as compared to female diabetic patients which is contrary to the previous findings^13,14,24. This difference may because 80% of the subjects in the present study were males.

 

Chest pain is the warning symptom of ACS, that alerts the patient and physician to the likelihood of underlying coronary artery disease. Absence of chest pain has major implication in its management as it results in delay in identification, diagnosis and management.  High prevalence of silent acute coronary event without the presence of chest pain among diabetic patients must alert the health care providers. The health care providers have significant role in preventing ACS and associated co-morbidities in diabetic and other high-risk patients^25,26. Early identification of ACS in diabetic patients based on atypical symptoms is vital for the initiation of immediate intervention. To facilitate early transfer to hospital, patients with diabetes and their caregivers must be educated by the health care providers about the symptomatology of ACS with special emphasis on atypical symptoms²⁷. But more evidences are required on large cohorts of diabetic and non- diabetic patients to compare the symptomatology of ACS. This may also provide evidences on specific atypical symptoms of ACS present in patients with diabetes mellitus.

 

CONCLUSION:

As per the present study findings, chest pain is less prevalent as an initial symptom of ACS in patients of diabetes and the diabetic patients may experience various atypical symptoms other than chest pain during ACS. Dyspnea, syncope/ giddiness were the major symptoms experienced by diabetic patients during ACS as compared to non-diabetic patients. Appropriate measures must be taken for diabetic patients by the health care providers to facilitate early and adequate management of ACS.

 

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Received on 01.10.2018         Modified on 02.11.2018

Accepted on 03.12.2018      ©A&V Publications All right reserved