title: Association between comorbidities and absence of chest pain in acute coronary syndrome with in-hospital outcome.
abstract: BACKGROUND
  To evaluate the impact of comorbidities on the management and outcomes of acute coronary syndrome (ACS) patients without chest pain/discomfort (i.e. ACS without typical presentation).
  
  
  METHODS
  Of the 11,458 ACS patients, enrolled by the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC; ClinicalTrials.gov: NCT01218776), 8.7% did not have typical presentation at the initial evaluation, and 40.2% had comorbidities. The odds of atypical presentation increased proportionally with the number of comorbidities (odds ratio [OR]: 1, no-comorbid; OR: 1.64, 1 comorbidity; OR: 2.52, 2 comorbidities; OR: 4.57, ≥3 comorbidities).
  
  
  RESULTS
  Stratifying the study population by the presence/absence of comorbidities and typical presentation, we found a decreasing trend for use of medications and percutaneous intervention (OR: 1, typical presentation and no-comorbidities; OR: 0.70, typical presentation and comorbidities; OR: 0.23, atypical presentation and no-comorbidities; OR: 0.18, atypical presentation and comorbidities). On the opposite, compared with patients with typical presentation and no-comorbidities (OR: 1, referent), there was an increasing trend (p<0.001) in the risk of death (OR: 2.00, OR: 2.52 and OR: 4.83) in the above subgroups. However, after adjusting for comorbidities, medications and invasive procedures, atypical presentation was not a predictor of in-hospital death. Independent predictors of poor outcome were history of stroke (OR: 2.04), chronic kidney disease (OR: 1.57), diabetes mellitus (OR: 1.49) and underuse of invasive procedures.
  
  
  CONCLUSIONS
  In the ISACS-TC, atypical ACS presentation was often associated with comorbidities. Atypical presentation and comorbidities influenced underuse of in-hospital treatments. The latter and comorbidities are related with poor in-hospital outcome, but not atypical presentation, per se.
authors.affiliation: Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy.
authors.forename: Olivia
authors.initials: O
authors.lastname: Manfrini
authors.affiliation: Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy.
authors.forename: Beatrice
authors.initials: B
authors.lastname: Ricci
authors.affiliation: Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy.
authors.forename: Edina
authors.initials: E
authors.lastname: Cenko
authors.affiliation: Clinical Emergency Hospital Bucharest, Cardiology Department, Bucharest, Romania.
authors.forename: Maria
authors.initials: M
authors.lastname: Dorobantu
authors.affiliation: University Clinic of Cardiology, University "Ss. Cyril and Methodius", Skopje, Macedonia.
authors.forename: Oliver
authors.initials: O
authors.lastname: Kalpak
authors.affiliation: University Clinic of Cardiology, University "Ss. Cyril and Methodius", Skopje, Macedonia.
authors.forename: Sasko
authors.initials: S
authors.lastname: Kedev
authors.affiliation: Clinical Center of Montenegro, Center of Cardiology, Podgorica, Montenegro.
authors.forename: Božidarka
authors.initials: B
authors.lastname: Kneževic
authors.affiliation: Institute of Natural Sciences, University of Physical Education, Budapest, Hungary; Department of Physiology, New York Medical College, Valhalla, NY, USA.
authors.forename: Akos
authors.initials: A
authors.lastname: Koller
authors.affiliation: Department for Cardiovascular Diseases, University of Zagreb, Zagreb, Croatia.
authors.forename: Davor
authors.initials: D
authors.lastname: Milicic
authors.affiliation: Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia.
authors.forename: Zorana
authors.initials: Z
authors.lastname: Vasiljevic
authors.affiliation: Cardiovascular Research Center, CSIC-ICCC, Hospital de la Santa Creu i Sant Pau, Institute Carlos III, Autonomous University of Barcelona, Barcelona, Spain.
authors.forename: Lina
authors.initials: L
authors.lastname: Badimon
authors.affiliation: Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy. Electronic address: raffaele.bugiardini@unibo.it.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Bugiardini
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D002637:Chest Pain / Q000209:etiology*; D015897:Comorbidity; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data*; D012042:Registries; D012307:Risk Factors
chemical_list: D002317:Cardiovascular Agents
keywords: Acute coronary syndrome; Chest pain; Chronic kidney disease; Comorbidity; Heart failure; Stroke