acute coronary syndrome, adverse cardiac event, pain, prodromal symptoms



  1. O'Keefe-McCarthy, Sheila PhD, RN
  2. Ready, Linda RN, BNSc, CNCC(C)


Background: Recognition of specific and nonspecific cardiac-related prodromal symptoms, indicative of myocardial ischemia, is critical for preemptive coronary heart disease (CHD) screening and effective diagnosis and treatment. In this systematic review, we examined whether prodromal symptoms were predictive of acute symptom presentations, cardiac events, or treatment interventions.


Methods: Studies that measured the association of prodromal symptoms with acute coronary syndrome (ACS) symptom presentation, acute cardiac event, and/or intervention in men and/or women with confirmed CHD were included. Data sources: Electronic searches in the Cochrane Library, MEDLINE, PubMed, PsyhINFO, Embase, CINAHL, and Scopus databases from 1990 to 2013 were conducted using medical subject heading terms including prodromal symptoms, ACS, acute myocardial infarction, unstable angina, and CHD.


Key words such as shortness of breath, anxiety, atypical pain, sleep disturbance, fatigue, and nausea/vomiting were also used. Abstracts, relevant journals, key authors, and reference lists were reviewed.


Results: Seven studies that included 6716 individuals with prodromal symptoms (65.7% women). Mean age was 68 +/- 13 and 58.5 +/- 9 years for women and men, respectively. Cardiac-related prodromal symptoms were predictive of patients' ACS-related symptoms and associated events from 3 to 24 months. Across studies, the prodromal symptoms consistently reported before cardiac event were chest discomfort/pain (n = 4, 57%), arm pain/discomfort (n = 6, 86%), jaw pain (n = 3, 43%), back/shoulder blade pain (n = 3, 43%), unusual fatigue (n = 7, 100%), shortness of breath (n = 6, 86%), sleep disturbance (n = 2, 29%), dizziness (n = 3, 43%), headache (n = 3, 43%), anxiety (n = 7, 100%), and gastrointestinal complaints (nausea, vomiting, indigestion; n = 5, 71%). Patients with prodromal arm, jaw, and back pain; fatigue; and shortness of breath had increased risk of experiencing similar symptoms during an ACS episode. Prodromal symptoms were predictive of adverse cardiac events and cardiac interventions. There is some preliminary evidence to suggest that prodromal symptoms of headache, sleep disturbance, and anxiety may predict ACS symptom presentation during an acute cardiac event.


Conclusion: Future research is warranted that would examine prospectively the predictive value of prodromal headache, sleep disturbance, and anxiety within this cardiovascular population on major adverse cardiac events. Preemptive screening for cardiac-related prodromal symptoms in men and women should be considered as a standard in clinical practice. This may potentiate early diagnosis, effective risk modification, timely pain management, and treatment intervention and decrease CHD-related morbidity and mortality.