A Specific Predictor of STSegment Elevation Myocardial Infarction Among the Symptoms of Acute Coronary Syndrome: Sweating In Myocardial Infarction (SWIMI) Study Group

Clinical Investigations
Sweating: A Specific Predictor of ST-Segment
Elevation Myocardial Infarction Among the
Symptoms of Acute Coronary Syndrome:
Sweating In Myocardial Infarction (SWIMI)
Study Group

Address for correspondence:
Bhanwar Lal Ranwa, MD
Department of Cardiology
Jawaharlal Nehru Medical College
and Hospital
Ajmer, Rajasthan, India, Pin-305001


Rajendra K. Gokhroo, MBBS, MD, FACC; Bhanwar L. Ranwa, MBBS, MD; Kamal Kishor,
MBBS, MD; Kumari Priti, MBBS, MD; Avinash Ananthraj, MBBS, MD; Sajal Gupta, MD;
Devendra Bisht, MD
Department of Cardiology, Jawaharlal Nehru Medical College and Hospital, Ajmer, Rajasthan,
India

Background: Today, cardiologists seek to minimize time from symptom onset to interventional treatment for
the most favorable results.
Hypothesis: In the acute coronary syndrome (ACS) symptom complex, sweating can differentiate ST-segment
elevation myocardial infarction (STEMI) from non–ST-segment elevation ACS (NSTE-ACS) during early hours
of infarction.
Methods: This single-center, prospective, observational study compared symptoms of STEMI and NSTE-ACS
patients admitted from August 2012 to July 2014.
Results: Of 12 913 patients, 90.56% met ACS criteria. Among these, 22.51% had STEMI. Typical angina was
the most common symptom (83.82%). On stepwise multiple regression, sweating (odds ratio: 97.06, 95%
confidence interval [CI]: 82.16-114.14, P < 0.0001) and typical angina (odds ratio: 2.72, 95% CI: 2.18-3.38,

P < 0.001) had significant association with STEMI. For diagnosis of STEMI, positive likelihood ratio (LR) and
positive predictive value (PPV) were highest for typical angina with sweating (LR: 11.17, 95% CI: 10.31-12.1;
PPV: 76.09, 95% CI: 74.37-77.75), followed by sweating with atypical angina (LR: 3.6, 95% CI: 3.07-4.21; PPV:
50.61, 95% CI: 46.45-54.76), typical angina (LR: 1.05, 95% CI: 1.03-1.07; PPV: 22.97, 95% CI: 22.11-23.84), and
atypical angina (LR: 0.77, 95% CI: 0.69-0.87; PPV: 18.09, 95% CI: 16.32-19.97). C statistic values of 0.859 for
typical angina with sweating and 0.519 for typical angina alone reflected high discriminatory value of sweating
for STEMI prediction.
Conclusions: Presence of sweating with ACS symptoms predicts probability of STEMI, even before clinical
confirmation. Sweating in association with typical or atypical angina is a much better predictor of STEMI than
NSTE-ACS.

Introduction
Failure to implement appropriate therapy in time is the major
cause of increased cardiovascular morbidity and mortality in
acute coronary syndrome (ACS) cases. Inability to deliver
any form of reperfusion therapy in about 30% of patients
and failure to minimize delays in reperfusion reflect missed
opportunities for improvement in care of acute ST-segment
elevation myocardial infarction (STEMI).1 Only 25% of all
patients presenting with suspected ACS in the emergency
department (ED) have a confirmed diagnosis of ACS at
discharge.2 Despite this, diagnosis of acute myocardial

The authors have no funding, financial relationships, or conflicts
of interest to disclose.

90

Clin. Cardiol. 39, 2, 90–95 (2016)
Published online in Wiley Online Library (wileyonlinelibrary.com)

DOI:10.1002/clc.22498 © 2015 Wiley Periodicals, Inc.

infarction (AMI) is missed in up to 11.1% of cases.3 Among
AMI cases, 18% do not have chest pain2 at presentation; an
initial 12-lead electrocardiogram (ECG) has a sensitivity of
only 20% to 60%; and a single set of biochemical markers
also has poor sensitivity.4 – 6
In this era of intervention, cardiologists around the
globe seek to minimize time from first medical contact
to device/needle time for the most favorable results. The
‘‘time is muscle’’ concept for viable myocardium cannot
be implemented unless patients present within a certain
window of time. So identification of event by patients
and primary-care physicians is as important as is the
golden hour of reperfusion. We undertook this study to
discover any ‘‘red flags’’ in the ACS symptom complex
that could identify STEMI with precision during the early
Received: August 20, 2015
Accepted with revision: November 1, 2015


hours of infarction. This red flag might increase community
awareness and clinical acumen of health care professionals,
thereby improving event-to-reperfusion time (ie, time from
event onset to reperfusion).

Methods
Study Patients
This was a prospective, single-center, observational study
that included 12–913 patients admitted to the coronary

care unit from August 1, 2012, to July 31, 2014, with
presumed diagnosis of ACS after meticulous screening in
the ED (Figure 1). We included patients age ≥30 years
who presented to the ED with a chief symptom of chest,
arm, jaw, or epigastric pain or discomfort, shortness of
breath, dizziness, palpitations, syncope, or other symptoms
suggestive of ACS. Cases with suspected pulmonary
thromboembolism and known cases of coronary artery
disease or heart failure were excluded from the study.
Clinical data was recorded by multiple on-duty cardiology
fellows. History was self-narrated and leading questions
were asked according to a preset questionnaire. Other data
of interest included sociodemographic information, ECG
findings, serial creatine kinase MB (CK-MB)/troponin T
(TnT), and echocardiography. Discharge diagnosis was
made by the senior ward physician and confirmed by a
senior cardiologist.
Analysis of Data
Diagnosis was confirmed on the basis of ECG, serial
CK-MB/TnT measurements, and echocardiography as per
universal definition of myocardial infarction (MI). Unstable
angina (UA) was defined as angina pectoris (or equivalent
type of ischemic discomfort) with ≥1 out of 3 features:
(1) occurring at rest (or minimal exertion) and usually
lasting >20 minutes (if not interrupted by the administration
of a nitrate or an analgesic); (2) being severe and
usually described as frank pain; or (3) occurring with
a crescendo pattern (ie, pain that awakens the patient
from sleep or that is more severe, prolonged, or frequent
than previously).7 Non–ST-segment elevation myocardial

infarction (NSTEMI) was as defined as ≥1 measurement of
CK-MB >10 μg/L or TnT >0.1 μg/L in the context of UA
with absent ECG criteria for STEMI.8 ST-segment elevation
myocardial infarction was defined as a clinical syndrome
with characteristic symptoms of myocardial ischemia in
association with persistent ECG ST-segment elevation and
subsequent release of biomarkers of myocardial necrosis.
Diagnostic ST-segment in the absence of left ventricular
(LV) hypertrophy or left bundle branch block was defined
as new ST-segment at the J point in ≥2 contiguous leads of
≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women
in leads V2 through V3 and/or of ≥1 mm (0.1 mV) in
other contiguous chest leads or the limb leads. New or
presumably new left bundle branch block at presentation,
ST-segment depression in ≥2 precordial leads (V1 through
V4 ) diagnostic of posterior-wall STEMI, and multi-lead STsegment depression with coexistent ST-segment elevation
in lead aVR were also included in the STEMI group.9 – 13
Symptoms were classified as typical angina and atypical

Figure 1. Flow of patients in SWIMI study. Abbreviations: NSTE-ACS,
non–ST-segment elevation acute coronary syndrome; STEMI, ST-segment
elevation myocardial infarction; SWIMI, Sweating In Myocardial
Infarction; USA, unstable angina.

angina/angina equivalent. Typical angina was defined as
substernal chest discomfort with a characteristic quality
and duration that was provoked by exertion or emotional
stress and relieved by rest or nitroglycerin.14 The rest of
the symptoms suggestive of acute ischemia were grouped
as atypical angina/angina equivalent. Sweating was used as

synonymous to diaphoresis, defined as profuse drenching
sweats inappropriate to the physical and environmental
state.
Statistical Analysis
The statistical analyses were done using SPSS version
20 (IBM Corp., Armonk, NY). Odds ratios (OR) were
calculated for the association between each potential risk
factor and STEMI. We considered 95% confidence intervals
(CIs) that excluded unity, or, equivalently, P < 0.05, as
statistically significant. Univariate analysis was done to find
statistically significant symptoms, which were then analyzed
using multivariate logistic regression. In the multivariable
analysis, the probability of STEMI was predicted using
multiple logistic regression. All independent variables
(symptoms) were entered in the regression models as
categorical variables. Starting with the full multivariable
model with all independent variables included, we excluded
1 insignificant independent variable at a time, starting with
the variable with highest P value, until only significant and
important predictors remained. Likelihood ratios (LR) and
predictive values (PV) of different symptoms for STEMI
were also calculated. The area under the receiver operating
characteristic curve (ROC) was used as an overall measure
of the discrimination abilities of different symptoms. The
area under ROC, measured in percent, can be interpreted
as the probability that a randomly chosen patient with a
particular symptom has a higher probability of STEMI than
a randomly chosen patient without that symptom.

Results

Among 12 913 patients, 11 695 (90.56%) were admitted
with the diagnosis of ACS and 1218 (9.44%) patients had
Clin. Cardiol. 39, 2, 90–95 (2016)
R.K. Gokhroo et al. Sweating as a predictor of STEMI
Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI:10.1002/clc.22498 © 2015 Wiley Periodicals, Inc.

91


nonischemic chest pain. Of the ACS patients, 2474 had
STEMI and 9221 had non–ST-segment elevation acute
coronary syndrome (NSTE-ACS). For 223 patients with
STEMI, their history could not be elicited as they presented
to the ED in a moribund state (due to cardiogenic shock,
stroke, ventricular fibrillation, or sudden cardiac death);
therefore, they were excluded from the analysis. Six
hundred five patients from the NSTE-ACS group could
not be further evaluated and were excluded. One hundred
fifty-nine patients admitted with NSTE-ACS developed late
ST-segment elevation and were included in the STEMI
group. Thus, the final cohort comprised 10 867 patients. Of
these, 2410 (22.18%) patients had STEMI, 6751 (62.12%)
had UA, and 1706 (15.7%) patients had NSTEMI. In our
cohort, the majority of patients were in the age group of
51 to 70 years. Out of all patients, 6781 (62.49%) were
male and 4086 (31.6%) were female. The NSTE-ACS group
had more females than did the STEMI group (42.08%
vs 21.87%; P < 0.0001). The NSTE-ACS patients had a
higher prevalence of diabetes mellitus (32.43% vs 18.58%;

P < 0.0001), hypertension (34.24% vs 27.30%; P < 0.0001),
and dyslipidemia (38.61% vs 26.68%; P < 0.0001) than the
STEMI group (Table 1). The site of infarction was anterior
in 56.72%, inferior in 40.29%, posterolateral in 1.83%, lateral
in 1.08%, and isolated right ventricular infarction in 0.08%.
In the study cohort, typical angina (83.82%) was the most
common presenting symptom in the ACS population, with
greater prevalence in the STEMI group than in the NSTEACS group (86.80% vs 82.97%, P < 0.0001; Table 1). Sweating
was present in 90.95% of STEMI and 10.43% of NSTE-ACS
patients (P < 0.0001). On univariate analysis, all symptoms
except nausea (P = 0.225) and palpitations (P = 0.364) were
found to have significant association with STEMI. These
significant independent variables were then analyzed using
multivariate analysis. Using backward stepwise multiple
logistic regression, 2 independent variables, typical angina
(OR: 2.72, P < 0.0001) and sweating (OR: 97.06, P < 0.0001),
were the only significant predictors of STEMI. Sweating
(28.29%) in the context of ACS had the highest odds (OR:
97.06, P < 0.0001) of favoring STEMI. Arm pain (OR: 1.06,
P = 0.437), back pain (OR: 1.03, P = 0.709), epigastric pain
(OR: 1.01, P = 0.891), dyspnea (OR: 1.06, P = 0.57), nausea
(OR: 1.05, P = 0.557), vomiting (OR: 1.17, P = 0.83), and
vertigo (OR: 1.31, P = 0.487) favored STEMI over NSTEACS, whereas palpitations (OR: 0.99, P = 0.99), mouth
dryness (OR: 0.82, P = 0.049), chest pain other than typical
angina (OR: 0.70, P = 0.099), and throat pain (OR: 0.97,
P = 0.656) favored NSTE-ACS over STEMI (Figure 2).
The ROC curve was plotted to estimate the discriminatory
performance of the logistic-regression model. The C statistic
value of typical angina with sweating for diagnosis of STEMI
was 0.859, compared with 0.519 for typical angina alone.

To evaluate the impact of sweating for diagnosis of
STEMI, all ACS symptoms were grouped into 2 categories,
typical angina and atypical angina or angina equivalents.
Atypical symptoms were more common in the NSTE-ACS
group (17.03% vs 13.2%; P < 0.0001). Despite being the most
common clinical presentation (86.8%), typical angina had
a low PPV (22.97), low LR (0.05), and low OR (1.35) for
diagnosis of STEMI (Table 2).

92

Clin. Cardiol. 39, 2, 90–95 (2016)
R.K. Gokhroo et al. Sweating as a predictor of STEMI
Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI:10.1002/clc.22498 © 2015 Wiley Periodicals, Inc.

Presence of sweating in the context of typical angina
increased PPV from 22.97 to 76.09, LR from 1.05 to 11.17,
and OR from 1.35 to 111.11 for STEMI. Likewise, presence
of sweating in the context of atypical angina improved PPV
from 18.09 to 50.61, LR from 0.77 to 3.60, and OR from 0.74
to 45.45.
Among all ACS symptoms, typical angina with sweating
had the highest PPV (76.09), positive LR (11.17), and OR
(111.11) for diagnosis of STEMI. Presence of sweating
markedly improved the statistical significance of anginal
symptoms for diagnosis of STEMI (Table 2, Figure 3).
On subgroup analysis, 159 STEMI patients initially did
not meet the ECG criteria in the ED, and diagnostic ECG
changes evolved after hospitalization. The majority of them,

142 (89.3%), had sweating at presentation. This implies
the significance of symptoms for timely diagnosis and
management of STEMI.

Discussion
Diagnosis of STEMI with history has always been a
clinical dilemma. Its diagnosis is delayed due to lack of
specificity of any symptom, delayed patient presentation,
and temporal delay in obtaining supporting evidence of
biochemical parameters, ECG, and echocardiography. This
study analyzed the symptoms of STEMI and NSTE-ACS
patients to see if any emerged as potential indicators for
early diagnosis of STEMI.
Typical angina was most common presentation in both
groups. In the STEMI group, 13.2% of patients, and 17.03%
in the NSTE-ACS group, had complaints other than typical
angina, which is on par with observations by Pope and
colleagues.2 Chest-pain characteristics and duration are
subjective and lack sound clinical evidence to pitch them for
STEMI diagnosis. In a meta-analysis by Chun and McGee15
and Panju et al,16 chest-pain characteristics such as pressure
and the like were not enough to be independently useful
in establishing a MI diagnosis. Classic duration of pain
lasting >30 minutes can be indicative of either an AMI or a
nonischemic etiology, like gastroesophageal disease.17,18
In a meta-analysis of 64 studies, chest-pain duration
>30 minutes suggested low likelihood of MI (LR+: 0.1).15
Several studies have examined the ability of associated
symptoms such as nausea, vomiting, and diaphoresis to
predict AMI. Two meta-analyses discovered that nausea

and diaphoresis predict AMI.15 Nattel et al noted sweating
in 53% of AMI cases. Diaphoresis was a more specific but
less sensitive predictor of MI than prolonged chest pain.19
However, in the Evaluation Study of Congestive Heart
Failure and Pulmonary Artery Catheterization Effectiveness
(ESCAPE) trial, the association between diaphoresis
and AMI disappeared on multivariable testing (OR: 1.1,
P = 0.636).6 Underrepresentation of patients in older age
groups and non–English-speaking ethnic groups probably
underestimated the association of sweating.
In our Sweating In Myocardial Infarction (SWIMI) study
cohort, sweating and typical angina were the only significant
symptoms for STEMI prediction. Sweating when added to
angina, whether typical or atypical, improved the diagnostic
accuracy of the symptom for STEMI in all statistical
domains. Typical angina with sweating had the highest
PPV and LR for STEMI.


Table 1. Baseline Characteristics and Symptom Profile of ACS Patients
Total Patients, N = 10 867

STEMI Patients, n = 2410

NSTE-ACS Patients, n = 8457

P Value

989 (9.10)

221 (9.17)

768 (9.08)

0.925

41–50

1618 (14.89)

546 (22.66)

1072 (12.67)

<0.0001

51–60

3230 (29.72)

722 (29.96)

2508 (29.66)

0.793

61–70

3116 (28.67)

588 (24.70)

2588 (30.60)

<0.0001

71–80

1654 (15.22)

277 (11.49)

1377 (16.28)

<0.0001

>80

260 (2.40)

56 (2.32)

204 (2.41)

0.860

Male sex

6781 (62.49)

1883 (78.13)

4898 (57.92)

<0.0001

Smoker

6310 (58.06)

1408 (58.42)

4902 (57.96)

0.704

DM

3191 (29.36)

448 (18.58)

2743 (32.43)

<0.0001

HTN

3554 (32.70)

658 (27.30)

2896 (34.24)

<0.0001

Obesity

2868 (26.39)

621 (25.76)

2247 (26.57)

0.446

Dyslipidemia

3908 (35.96)

643 (26.68)

3265 (38.61)

<0.0001

778 (7.16)

121 (5.02)

657 (7.77)

<0.0001

Typical angina

9109 (83.82)

2092 (86.80)

7017 (82.97)

<0.0001

Arm pain

4965 (45.69)

1179 (48.92)

3786 (44.77)

0.437

Back pain

4411 (40.59)

1072 (44.48)

3339 (39.48)

0.709

Epigastric pain

3685 (33.91)

874 (36.27)

2811 (33.24)

0.891

Throat pain

3258 (29.98)

786 (32.61)

2472 (29.23)

0.656

Sweatinga

3074 (28.29)

2192 (90.95)

882(10.43)

<0.0001

Palpitations

2619 (24.10)

564 (23.40)

2055 (24.30)

0.990

Nausea

2494 (22.95)

531 (22.03)

1963 (23.21)

0.557

Vomiting

1837 (16.90)

504 (20.91)

1333 (15.76)

0.083

Dry mouth

1355 (12.47)

370 (15.35)

985 (11.65)

0.049

1231 (11.33)

315 (13.07)

916 (10.83)

0.578

441 (4.06)

53 (2.20)

388 (4.59)

0.099

141 (1.29)

12 (0.50)

129 (1.53)

0.487

Variable
Age, y
≤40

CKD
Symptoms

Dyspnea
Other chest pain
Vertigo

b

Abbreviations: ACS, acute coronary syndrome; CKD, chronic kidney disease; DM, diabetes mellitus; HTN, hypertension; NSTE-ACS, non–ST-segment
elevation acute coronary syndrome; STEMI, ST-segment elevation myocardial infarction.
Data are presented as n (%).
a
Sweating refers to profuse sweating in context of ACS. b Chest pain other than typical angina.

Twenty percent of AMI and 37% of UA patients can present
with an initially normal ECG.2 In our study, presence
of sweating in 142 patients in the ED without diagnostic

ECG changes, who later on developed STEMI, echoes the
significance of this symptom. Paying due regard to this
symptom in the ED may help to diagnose STEMI in the
hyperacute phase.
A probable explanation of profuse sweating in STEMI
is stimulation of the sympathetic nervous system as a

protective phenomenon in response to pain. But this does
not explain absence of profuse sweating in other diseases
with severe pain, like trauma, burns, colic, pancreatitis,
and others. A second explanation is transient hypotension
due to acute myocardial stunning in STEMI activating the
sympathetic nervous system, instantaneously resulting in
profuse sweating. Lack of transmural infarction in NSTEMI,
and absence of such severe acute insult, may explain the
absence of sweating in this group. We propose that there
Clin. Cardiol. 39, 2, 90–95 (2016)
R.K. Gokhroo et al. Sweating as a predictor of STEMI
Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI:10.1002/clc.22498 © 2015 Wiley Periodicals, Inc.

93


Figure 2. Odds ratio plot of ACS symptoms on multivariate analysis. Abbreviations: ACS, acute coronary syndrome; CI, confidence interval; NSTE-ACS,
non–ST-segment elevation acute coronary syndrome; OR, odds ratio; STEMI, ST-segment elevation myocardial infarction.
Table 2. Analysis of Symptoms for Prediction of STEMI
Total patients,
N (%)

STEMI, n (%)

NSTE-ACS,
n (%)

PPV (95% CI)

LR+ (95% CI)

OR (95% CI)

P Value

Typical angina with
sweatinga

2497 (22.98)

1900 (78.84)

597 (7.06)

76.09 (74.37-77.75)

11.17 (10.31-12.1)

111.11 (90.91-125.00)

<0.0001

Typical angina

9109 (83.82)

2092 (86.80)

7017 (82.97)

22.97 (22.11-23.84)

1.05 (1.03-1.07)

1.35 (1.18-1.54)

<0.0001

Atypical
angina/angina
equivalents with
sweatinga

577 (5.31)

292 (12.12)

285 (3.37)

50.61 (46.45-54.76)

3.6 (3.07-4.21)

45.45 (30.30-71.43)

<0.0001

Atypical
angina/angina
equivalents

1758 (16.18)

318 (13.20)

1440 (17.03)

18.09 (16.32-19.97)

0.77 (0.69-0.87)

0.74 (0.65-0.84)

<0.0001

Symptom

Abbreviations: ACS, acute coronary syndrome; CI, confidence interval; LR+, positive likelihood ratio; NSTE-ACS, non–ST-segment elevation acute coronary
syndrome; OR, odds ratio; PPV, positive predictive value; STEMI, ST-segment elevation myocardial infarction.
a
Sweating refers to profuse sweating in context of ACS.

might be some cross connection between the sympathetic
nervous system innervating sweat glands and myocardial
pain fibers, which have the same origin in the thoracolumbar
region. So, parallel to the theory of referred pain, sweating
could be a referred symptom, though this theory needs
further validation.
In today’s world, when time to treatment is a quality
metric for acute STEMI care,20 we propose that this
parameter should be expanded to event-to-reperfusion
time. Because reperfusion salvages injured and not-dead
myocardium, patients presenting late will have dead
reperfused myocardium. Improving time to treatment will
have suboptimal results unless patients or primary-care

94

Clin. Cardiol. 39, 2, 90–95 (2016)
R.K. Gokhroo et al. Sweating as a predictor of STEMI
Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI:10.1002/clc.22498 © 2015 Wiley Periodicals, Inc.

physicians suspect STEMI in time. Quality of care should
now focus on event-to-reperfusion time, rather than time
to treatment, to target unmet health goals. Sweating with
typical STEMI symptoms can help emergency responders
and ED staff have a high level of suspicion for STEMI, but
treatment decisions should still be based on ECG criteria.

Study Limitations
Our study is a single-center study, and to further validate

our observations, a multicenter study is needed. Patient
history was noted by multiple observers, so the chance of
interobserver variation does exist. Variations in symptoms


Figure 3. Histogram showing PPV, OR, and LR values of typical and atypical angina symptoms with or without associated sweating. Abbreviations: LR,
positive likelihood ratio; OR, odds ratio; PPV, positive predictive value.

due to different educational qualifications and interpretation
by patients may have affected study results.

Conclusion
In the SWIMI study, presence of sweating with ACS
symptoms significantly increased probability of STEMI.
Sweating in association with typical or atypical angina
was the strongest predictor of STEMI. Moreover, eventto-treatment time, rather than time to treatment, should
be the goal of STEMI medical care. If sweating becomes
widely understood to be a red flag for STEMI, community
awareness of this simple and inexpensive symptom tool can
save many lives and health care dollars.

8.

9.

10.

11.

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