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Pak J Med Sci 2013 Vol. 29 No. 2 www.pjms.com.pk 565
Open Access
INTRODUCTION
Acute myocardial infarction (AMI) is a cardiac
emergency. The clinical diagnosis of AMI requires
an integrated assessment of the history especially
with reference to chest pain along with some
combination of indirect evidences of myocardial
infarction using biochemical, electrocardiographic,
and imaging modalities. In the United States,
nearly one million patients suffer from AMI per
year1. Even in Pakistan 46 % of the deaths are due
to myocardial infarction and 27% are due to other
subsets of Ischemic heart disease2.
1. Dr. Muhammad Ajmal Malik, MBBS, MD,
Senior Registrar,
2. Dr. Shahzad Alam Khan, FCPS,
Senior Registrar,
3. Mr. Sohail Safdar, M. Sc,
ResearchOfcer,
4. Dr. Ijaz-Ul-Haque Taseer, MBBS, MD,
ChiefResearchOfcer,
1-2: Nishtar Hospital Multan, Pakistan.
3-4: PMRC Research Centre, Nishtar Medical College, Multan, Pakistan.
Correspondence:
Dr. Ijaz-Ul-Haque Taseer, MBBS, MD,
E-mail: dritaseer@hotmail.com, pmrcnmc@gmail.com
* Received for Publication: September 4, 2012
* Revision Received: January 12, 2013
* Revision Accepted: January 15, 2013
Original Article
Chest Pain as a presenting complaint in patients
with acute myocardial infarction (AMI)
Muhammad Ajmal Malik1, Shahzad Alam Khan2,
Sohail Safdar3, Ijaz-Ul-Haque Taseer4
ABSTRACT
Objective: To study various characteristics of chest pain in acute myocardial infarction patients.
Methodology: A total of 331 patients of AMI admitted at Cardiology unit Nishtar Hospital Multan and
Chaudhry Pervez Elahi Institute of Cardiology Multan, irrespective of the age and gender, were included
in this study. The study duration was one year starting from June 2011 to June 2012. Non-probability
purposive sampling technique was used in this descriptive study. Informed consent to participate in this
study was taken. Data were entered and analyzed using SPSS-11.
Results: A total number of 331 patients with AMI were included in the study. Mean age was 54.99±11.25
years with minimum age 20 years and maximum age 90 years. It included 264(79.8%) male and 67(20.2%)
female patients with male to female ratio of 3.9:1. Out of these 331 patients 308 (93.1%) patients reported
chest pain as the presenting complaint. Remaining 23(6.9%) presented with clinical features other than
chest pain. There were 127(38.4%) patients with pre-cordial chest pain, 115(34.7%) had retrosternal chest
pain, 58(17.5%) were having epigastric pain. Severe chest pain was seen in 281(84.9%) patients while
26(7.9%) had only mild chest discomfort. Radiation of the pain to shoulder, neck and jaw was seen in 75
(22.7%) patients. In 42(12.7%) patients, pain radiated to both sides of chest. Another 55(16.6%) patients
had pain radiation to chest, shoulder, upper arm and ulnar side of left forearm. Chest pain radiation to
interscapular region along with both sides of chest was present in 10(3.0%) patients. In 11(3.3%) patients’
pain radiated only to left side of chest. Pain persisting for >20 minutes was reported by 298 (90%) patients
while only 10(3.1%) had pain persisting for <20 minutes.
Conclusion: There is considerable overlap in chest pain of cardiac as well as non cardiac causes. However,
vigilant evaluation of characteristics of chest pain in history taking may help to overcome this dilemma.
Severe and prolonged precordial chest pain in a male patient between the age of 41-70 years, with pain
radiation to left shoulder, neck and jaw is highly suggestive of AMI.
KEY WORDS: Chest pain, acute myocardial infarction, Precordial chest pain.
doi: http://dx.doi.org/10.12669/pjms.292.2921
How to cite this:
Malik MJ, Khan SA, Safdar S, Taseer IH . Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI). Pak
J Med Sci 2013;29(2):565-568. doi: http://dx.doi.org/10.12669/pjms.292.2921
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
566 Pak J Med Sci 2013 Vol. 29 No. 2 www.pjms.com.pk
Chest pain is the most common presenting
complaint of acute myocardial infarction. The classic
manifestation of ischemia is usually described as
a heavy chest pressure or squeezing, a “burning”
feeling, or difculty in breathing. The discomfort or
pain often radiates to the left shoulder, neck, or arm.
Chest pain may be atypical in few cases. It builds
in intensity over a period of few minutes. The pain
may begin with exercise or psychological stress, but
acute myocardial infarction most commonly occurs
without obvious precipitating events.
Each year ve million patients come to
emergency departments with chest pain.3 However,
diagnostic evaluation reveals that only 15 to 25
percent of patients with acute chest pain actually
have acute coronary syndrome.4,5 The difculty
is to discriminate patients with acute coronary
syndrome from those with non-cardiac chest pain.
Pope et al found that only 2.1 percent of patients
with chest pain having acute myocardial infarction
were discharged from the emergency department.6
Patients with acute myocardial infarction who
are mistakenly discharged from the emergency
department have short-term mortality rates of about
25 percent, at least twice what would be expected if
they were admitted.7
It is therefore of utmost importance to emphasize
the evaluation of chest pain and to discriminate
chest pain of acute myocardial infarction from non-
cardiac chest pain. By doing this, we can eliminate
the chances of mistaken discharge of patients with
acute myocardial infarction having initial normal
ECG. We can also decrease undue burden on health
personnel by avoiding mistaken admission of those
patients who do not actually have myocardial
infarction or acute coronary syndrome.
So the present study was conducted to nd out
the characteristic and peculiar features of chest pain
which can ultimately help in diagnosis of AMI.
METHODOLOGY
A total of 331 patients of AMI admitted at
Cardiology unit Nishtar Hospital Multan and
Chaudhry Pervez Elahi Institute of Cardiology
Multan, irrespective of the age and gender, were
included in this study. The study duration was one
year starting from June 2011 to June 2012. Non-
probability purposive sampling technique was
used in this descriptive study. Informed consent to
participate in this study was taken. A pre-designed
questionnaire was used to record the data. Data
were entered and analyzed using SPSS-11.
RESULTS
A total number of 331 patients with AMI were
included in the study. Mean age was 54.99±11.25
years with minimum age 20 years and maximum
age 90 years. It included 264(79.8%) male and
67(20.2%) female patients with male to female
ratio of 3.9:1. Out of these 331 patients 308 (93.1%)
patients reported chest pain as the presenting
complaint. Remaining 23(6.9%) presented with
clinical features other than chest pain.
Majority of the patients i.e. 278(83.98%) were be-
tween the age of 41-70 years. There were 22 (6.64%)
patients between the age of 71-90 years. Only
5(1.51%) were 30 years and below. (Table-I)
There were 127(38.4%) patients with pre-cordial
chest pain, 115(34.7%) had retrosternal chest pain,
58(17.5%) were having epigastric pain and only
2(0.6%) had pain in the back of chest as initial symp-
tom. Only 3 (0.9%) patients had pain both in epigas-
trium and retrosternum. Severe chest pain was seen
in 281(84.9%) patients while 26(7.9%) had only mild
chest discomfort.
Radiation of the pain to shoulder, neck and
jaw was seen in 75 (22.7%) patients. In 42(12.7%)
patients pain radiated to both sides of chest. Another
55(16.6%) patients had pain radiation to chest,
shoulder, upper arm and ulnar side of left forearm.
Chest pain radiation to interscapular region along
with both sides of chest was present in 10(3.0%)
patients. In 11(3.3%) patients’ pain radiated only
to left side of chest. Another 11(3.3%) had pain
radiation to ulnar side of arm only. Radiation
of pain to the left shoulder alone was present in
16(4.8%), to interscapular region alone in 9 (2.7%)
and to jaw alone in 4(1.2%) patients and 68 (20.5%)
did not describe radiation to any site.
Pain persisting for >20 minutes was reported by
298 (90%) patients while only 10(3.1%) had pain
persisting for <20 minutes. Ninety two (27.8%)
patients had sensation of heavy weight over chest.
Pain was constricting in 36 (10.6%), choking in
30(9.6%), burning in 48 (14.5%) and stab like in
Muhammad Ajmal Malik et al.
Table-I: Age wise distribution of AMI (n = 331).
Age Group Frequency Percentage
20-30 5 1.51
31-40 26 7.85
41-50 106 32.03
51-60 107 32.33
61-70 65 19.64
71-90 22 6.64
Total 331 100
Pak J Med Sci 2013 Vol. 29 No. 2 www.pjms.com.pk 567
42 (12.7%) patients. Only 2(0.6%) had reported
both choking and constricting pain while, another
2(0.6%) had choking as well as burning character
chest pain. Acute myocardial infarction occurred
in morning time in 128(38.7%) patients, 98 (29.6%)
patients had AMI in evening while in 96(29.0 %)
AMI occurred at night and 9 (2.7%) patients could
not clearly describe the timing of onset.
DISCUSSION
Despite of all advances in the management of car-
diovascular diseases, yet discrimination between
chest pain due to AMI and non- cardiac chest pain
remains a dilemma. Unfortunately, not much litera-
ture is available about the characteristics of chest
pain to differentiate these two conditions. Only
three of the selected studies combined different
signs and symptoms for the diagnosis of AMI.8-10
Age is an important determinant of AMI in patients
having chest pain. Incidence of AMI increases with
increasing age. In females age of presentation is
even higher by 5-10 years.11 In our study, we found
that majority of the patients were between the age
of 41-70 years, while a study conducted by Malik
et al, 85% of the patients were between 41-60 years
of the age 2. Age of presentation was slightly higher
in our population as compared to that which was
noticed by British Heart Foundation i.e. 30-69
years.12 In Belgium Bartholomeeussen et al13 found
that incidence of AMI is high at the ages between
45–75 years. Our results are in accordance with
the study conducted by Bartholomeeussen et al.13
However the mean age for rst MI among south
Asian is lower compared to the individuals in other
countries.14
At any given age, prevalence of coronary heart
disease is greater in men than in women.15 Risk
factors like hypertension and hyperlipidemia are
more prominent for men than women in the late
40- to early 50-year range; then their prevalence is
higher in women. Women have an extra protection
during their early reproductive life due to the
effect of sex hormones. In our study majority of
the patients with AMI were male (79.8%). Studies
conducted by Hafeez et al and Shabbir et al also
showed male dominance 16, 17. Albarran et al18 had
also discovered that AMI is more common in males
(68%) as compared to females (32%). Chirsten et al19
found AMI prevalence was 62% in males. In a local
study conducted by Mujtaba et al20 at Karachi had
also similar ndings.
Site of the chest pain gives important clue to
the diagnosis of ACS/AMI. Pain which is located
in the center of chest is more likely to be ischemic
than a peripherally located chest pain. We found
that precordial chest pain is the most common
site for chest pain. There were 127(38.4%) patients
with precordial chest pain in our setting. De Silva
also noticed that precordial and retrosternal sites
are most common sites for chest pain in CAD.21
Bosner et al22 analysed 1212 patients (534 men and
678 women) for the aetiology of their chest pain;
of those 180 patients (92 men and 88 women) were
diagnosed as having CHD. Pain was present on
the left side of chest in 56 (63.6%) females and in
63 (68.5%) males. Bosner et al22 noticed that chest
pain was localized on the right side of the chest in
34.1% patients. However, in our settings none of the
patient presented with right sided chest pain.
Most common site where AMI pain radiates is left
shoulder and arm.23,24 This is because of presence of
heart on the left of chest, so pain radiates along left
sided cervical nerve roots. In our study 55(16.6%)
patients had pain radiation to left shoulder, left
upper arm and ulnar side of left forearm. Solt et al25
claimed a high prevalence of chest pain radiation
to the jaw especially in females. However, we
have noticed that only 4(1.2%) patients had pain
radiation to the jaw alone but pain radiation to the
jaw was present in combination with radiation to
shoulder and neck in 22.7% patients.
Duration of chest pain more than 20 minutes can
be taken as cutoff for AMI. In our study, it was
found that 90% of patients had chest pain persisting
for >20 minutes. Similar results have been proven
in multiple other international studies.26,27 However
those attacks of chest pain that are not very severe
or prolonged, but distressing enough for patients
to contact a general practitioner, present a more
difcult problem in diagnosis and management.28
Although chest pain is the most important
symptom of AMI but it may be invariably absent
in some patients. In our setting 6.9% patients had
symptoms other than chest pain (painless AMI).
In a study conducted by Hafeez et al pain less MI
was seen in 6 % of the patients16. Abidov et al29
also found that some patients may present with
symptoms other than chest discomfort; such as
“angina equivalent” symptoms include dyspnea
(most common), nausea and vomiting, diaphoresis,
and unexplained fatigue. Chest pain remains most
important symptom of AMI but in few patients it
may not be there. Further studies on large scale
are required about the characteristics of chest pain
favoring AMI.
Chest Pain as a presenting complaint in AMI
568 Pak J Med Sci 2013 Vol. 29 No. 2 www.pjms.com.pk
CONCLUSION
There is considerable overlap in chest pain of
cardiac as well as non cardiac causes. However,
vigilant evaluation of parameters of chest pain in
history taking may help to overcome this dilemma.
Severe and prolonged precordial chest pain in a
male patient between the age of 41-70 years, with
pain radiation to left shoulder, neck and jaw is
highly suggestive of AMI.
ACKNOWLEDGEMENT
The authors are thankful to Mr. Muhammad Ilyas
Qaisar, PMRC Research Centre, Nishtar Medical
College, Multan for his help in data entry.
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Muhammad Ajmal Malik et al.
