From the Guidelines
Diabetics often experience atypical chest pain during myocardial infarction (MI) due to diabetic neuropathy affecting the sensory nerves that transmit pain signals from the heart, as supported by the 2018 European Heart Journal study 1. This autonomic neuropathy, a common complication of long-standing diabetes, damages nerve fibers that normally detect cardiac ischemia, resulting in altered pain perception. Instead of the classic crushing or pressure-like chest pain, diabetic patients may experience vague symptoms such as:
- unusual fatigue
- shortness of breath
- nausea
- pain in atypical locations like the back, jaw, or abdomen This phenomenon, called "silent ischemia," is particularly dangerous as it can delay diagnosis and treatment of MI. The pathophysiology involves both microvascular damage and direct nerve injury from chronic hyperglycemia, which impairs nerve conduction and alters pain thresholds. Additionally, the metabolic abnormalities in diabetes affect how cardiac tissue responds to ischemia, potentially changing the nature of pain signals generated. Healthcare providers should maintain a high index of suspicion for MI in diabetic patients presenting with any unusual symptoms, even in the absence of typical chest pain, as emphasized in the 2013 Journal of the American College of Cardiology study 1. It is also important to note that diabetic patients are at higher risk of death and complications, including repeat revascularization after PCI, as stated in the 2018 European Heart Journal study 1. Therefore, it is crucial to prioritize the diagnosis and treatment of MI in diabetic patients presenting with atypical symptoms, and to consider the use of more potent oral P2Y12 receptor inhibitors, such as prasugrel or ticagrelor, as recommended in the 2018 European Heart Journal study 1.
From the Research
Atypical Chest Pain in Diabetics during MI
- Diabetics may experience atypical chest pain during myocardial infarction (MI) due to diabetic autonomic neuropathy, which can lead to underdiagnosis and delayed treatment 2.
- Cardiac autonomic neuropathy (CAN) is a serious complication of diabetes mellitus, strongly associated with an increased risk of cardiovascular mortality, and can manifest as "silent" myocardial infarction 3.
- Atypical chest pain in diabetic patients with suspected stable angina can lead to under-diagnosis of coronary disease and increase the risk of coronary events 4.
- A systematic review and meta-analysis found that patients with diabetes are less likely to experience chest pain during MI compared to those without diabetes, with a 43% higher likelihood of no chest pain in cohort and cross-sectional studies and a 44% higher likelihood in case-control studies 5.
Clinical Implications
- The presence of atypical chest pain in diabetics with MI is associated with higher mortality rates and worse clinical outcomes 2.
- Clinicians should consider an MI diagnosis when patients with diabetes present with atypical symptoms, and treatment protocols should reflect this 5.
- Early diagnosis and management of cardiac autonomic neuropathy are crucial to prevent cardiovascular complications in diabetic patients 3.
Risk Factors and Diagnosis
- Established risk factors for cardiac autonomic neuropathy include poor glycemic control, hypertension, dyslipidemia, and obesity 3.
- Methods of CAN assessment in clinical practice include assessment of symptoms and signs, cardiovascular reflex tests, short-term electrocardiography, and heart rate variability 3.
- Atypical chest pain in diabetic patients can be a challenge to diagnose, and a high index of suspicion is necessary to prevent delayed treatment and poor outcomes 4.