Jones, MM; (2012) A systematic review of whether people with DM experience less chest pain when having a myocardial infarction. Presented at: SAPC Annual Scientific Meeting, Glasgow, UK.

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Abstract

Abstract The problem People with diabetes mellitus (DM) are more likely to have a myocardial infarction (MI) compared to people without diabetes and they have a higher mortality from their myocardial infarction. DM autonomic neuropathy may lead to reduced pain perception and so under recognition of symptoms as anginal/ infarction pain by the patient and their clinician. This might have important implications as there may be delay in seeking assistance as early treatment of MI reduces both morbidity and mortality. There is conflicting research in this area. The approach Standard methods including searches of Pubmed / Embase using MOOSE criteria for meta analysis of observational data. Searches and data extraction were done by 2 people independently. Data was meta-analysed. Findings Searches identified 1566 abstracts,19 meeting our full criteria. Authors used a variety of classifications of symptoms such as absence of chest pain (CP), and typical /atypical (T/AT) classification. 19 papers identified patients with CP /no CP symptoms during an MI, those with DM having an odds ratio (OR) for CP during MI of 0.74 (0.62 to 0.89 n=471,723 I2 91%). However, one study dominates the review with 20 times the study size of all other studies and substantially contributes to this finding. Conversely three studies reported using T/AT showed a non significant increase in DM having typical symptoms OR 1.68 (0.91-3.11 n=492 I2 0%). Eight papers identified other non pain symptoms such as increased breathlessness among DM (OR 1.33 (1.17-1.50 n=6069 I2 0%). For other symptoms, we found slightly less extra cardiac pain (arm, neck pain 4 studies n=47264 studies (OR 0.78 0.68 to 0.90 I2) but no impact on sweating (7 studies OR 0.98 (0.86-1.13 n=4300 I2 0%) Consequences Patients with DM experience less CP, and more non pain symptoms such as breathlessness during their MI. This raises important issues for patients with DM (education about their disease) and their clinicians. As primary care clinicians are in frequent contact with this group attempts to change (lower) the threshold for referral to secondary care could be explored. Limitations of the review include significant study heterogeneity, issues around recruiting on the basis of CP (selection bias), identifying patients who are admitted to hospital (survivor bias) and failure to address gender, age and morbidity disparities between groups.

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