TITLE:
Beyond Chest Pain: Diagnostic Pathway Failures and Time-to-Treatment Disparities in Acute Coronary Syndrome—A Focused Narrative Review
AUTHORS:
Zaidan Khawaled, Amira Amara
KEYWORDS:
Acute Coronary Syndrome, Anginal Equivalent, Diagnostic Delay, Door-to-ECG, Reperfusion
JOURNAL NAME:
World Journal of Cardiovascular Diseases,
Vol.16 No.10,
October
20,
2026
ABSTRACT: Background: Acute coronary syndrome (ACS) pathways are commonly activated by chest pain, creating a systems vulnerability when myocardial ischaemia presents with dyspnoea, gastrointestinal symptoms, syncope, weakness or fatigue. Objective: To examine recent evidence on where recognition fails and how diagnostic and treatment delays can be measured. Methods: PubMed/ MEDLINE and Google Scholar were searched to July 2026 for adult ACS studies reporting symptom phenotype and triage, diagnostic or treatment intervals. Results: Contemporary studies consistently located the largest disparities early in care. In a 2021 PCI cohort, door-to-balloon time within 90 minutes was achieved in 40.0% of atypical presentations compared with 66.3% of typical presentations. A 2024 study found threefold higher odds of delayed reperfusion, while a 2025 STEMI cohort reported markedly higher odds of delayed door-to-ECG time. Conclusion: Symptom-inclusive triage, parallel cardiac evaluation and routine auditing of door-to-ECG, door-to-diagnosis and diagnosis-to-treatment intervals according to presenting symptom should be prioritised.