Atypical presentation and comorbidities mutually influence management of ACS patients

Background: Limited data are available on the association between comorbidities and acute myocardial ischemia with atypical presentation. Purpose: The aim of this study was to investigate the impact of comorbidities on the management and outcomes of ACS patients with atypical presentation (i.e. ACS without chest pain). Methods: Between 2010 and 2016, 11458 ACS patients were admitted at 57 hospitals included in the network of the ISACS-TC registry (ClinicalTrials.gov, NCT01218776). There were 1394 (12.2%) patients with unstable angina, 2855 (24.9%) with NSTEMI, and 7203 (62.9%) with STEMI. Results: 995 (8.7%) ACS patients have atypical presentation at the initial evaluation, and the 40.2% of the overall study population have comorbidities (diabetes mellitus, heart failure, CKD, COPD, stroke, PAD, GERD or active cancer). Patients with comorbidities were not equally distributed: 38.7% were with typical presentation and 55.2% without typical presentation, (p<0.001). In-hospital mortality rate was much higher in patients with atypical presentation than in patients with the typical one (15.5% vs 6.3%, p<0.001). As well, mortality rate was lower for ACS patients with no-comorbidities than for ACS patients with comorbidities (5.1% versus 10.1%, p<0.001). Stratifying the population by the presence/absence of comorbiditis and the presence/absence typical presentation, we found a decreasing trend in use of evidence base treatment (aspirin, beta-blocker, statin and reperfusion) and invasive procedure. Compare to patients with typical presentation and no-comorbidities (OR: 1, referent), patients with typical presentation and comorbidities (OR: 0.70), as well as those with atypical presentation and no-comorbidities (OR: 0.23), and those with atypical presentation and comorbidities (OR: 0.18) had a significant (p<0.001) lower probability to undergo in-hospital cardiac catheterization. On the opposite, there was an increasing trend (p<0.001) over subgroups in the risk of death (OR:1 referent, typical ACS presentation and no-comorbid; OR:2.00 typical ACS presentation and comordidities; OR: 2.52 atypical ACS presentation and no-comorbid; OR: 4.83 atypical ACS presentation and comordidities). Conclusions: The presence of comorbidities and atypical ACS presentation dramatically influence the process of care. Patients with atypical presentation and comorbidities are those who receive the lowest treatment and those who have the highest risk of in-hospital death.