• Pin Pin Pek, En Yun Loy, Win Wah, HoAndrew Fu WahAFW¶Emergency Medicine Residency Program,SingHealth Services,Singapore., Huili Zheng, Fook-ChongStephanie Man ChungSMC†Division of Research,Singapore General Hospital,Singapore., ChuaTerrance Siang JinTSJ**Department of Cardiology,National Heart Centre,Singapore., Tian Hai Koh, Khuan Yew Chow, Nan Liu, and OngMarcus Eng HockMEH*Department of Emergency Medicine,Singapore General Hospital,Singapore..
• *Department of Emergency Medicine,Singapore General Hospital,Singapore.
• Can J Emerg Med. 2017 Sep 1; 19 (5): 355-363.

ObjectiveEarly reperfusion therapy in the treatment of ST segment elevation myocardial infarction (STEMI) patients can improve outcomes. Silent myocardial infarction is associated with poor prognosis, but little is known about its effect on treatment delays. We aimed to characterize STEMI patients presenting without complaints of pain to the emergency departments (EDs) in Singapore.MethodsRetrospective data were requested from the Singapore Myocardial Infarction Registry (SMIR), a national level registry in Singapore. Painless STEMI was defined as the absence of pain (chest, back, shoulder, jaw, and epigastric pain) during ED presentation. The primary outcome was door-to-balloon (D2B) time, defined as the earliest time a patient arrived in the ED to balloon inflation. Secondary outcomes were 1-month and 1-year mortality and occurrence of adverse events.ResultsFrom January 2010 to December 2012, the SMIR collected 6412 cases; 10.9% of patients presented without any pain. These patients were older (median age =75 v. 58 years old), more likely to be females (39.9% v. 16.1%), Chinese (74.9% v. 62.7%), obese (median body mass index [BMI] =24.5 v. 22.1), and with history of hypertension (71.1% v. 54.6%), diabetes mellitus (48.6% v. 37.0%), and acute myocardial infarction (20.0% v. 12.3%). They had a longer median D2B (80.5 v. 63 minutes, p<0.001) and a higher occurrence of 30-day (38.4% v. 5.7%) and 1-year mortality rates (47.3% v. 8.5%).ConclusionA small proportion of STEMI patients presented without any pain to the ED. They tended to have a higher D2B and risks of mortality. Targeted effort is required to improve diagnostic and treatment efficiency in this group.

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