Prevalence, Clinical Characteristics, and Mortality Among Patients With Myocardial Infarction Presenting Without Chest Pain

Everyone knows a heart attack as crushing chest pain. This enormous registry study — more than 430,000 patients — shows how often, and how dangerously, that picture is wrong.

A full one-third of heart attack patients arrived without chest pain. They were disproportionately older, female, and diabetic, and the consequences of the missed signal were stark. They reached the hospital later, were far less likely to be diagnosed with a heart attack on arrival, and received fewer of the proven treatments — reperfusion, aspirin, beta-blockers. Their in-hospital mortality was 23 percent versus 9 percent for those with chest pain, and the analysis attributed much of that excess death to the delayed, less aggressive care that followed the atypical presentation.

The lesson is one of pattern recognition and humility. A heart attack does not always announce itself, and the patients whose symptoms are quietest are often those who can least afford the delay.

We rate the evidence strong. A registry of this scale gives unusually reliable estimates, and its message — that atypical heart attacks are common and lethal when missed — remains clinically vital.