Case Report, Int J Cardiovasc Res Vol: 8 Issue: 2
Atypical Myocardial Infarction: Beware Misdiagnosis of Acid Peptic Disease
Received: January 23, 2019 Accepted: February 15, 2019 Published: February 21, 2019
Citation: Mohsin I, Ahmed H (2019) Atypical Myocardial Infarction: Beware Misdiagnosis of Acid Peptic Disease. Int J Cardiovasc Res 8:2. doi: 10.4172/2324-8602.1000372
Early diagnosis of myocardial infarction (MI) and prompt intervention within one to two hours from the onset of pain significantly decreases mortality. Acute coronary syndrome (ACS) usually manifests as chest discomfort and occur mostly in elderly population. Hence, asymptomatic ACS event in younger population makes it a diagnostic challenge. Misdiagnosis and discharging of such patients can have dire consequences. Here, we report a case of young female presenting to emergency department with severe pain in abdomen which was later diagnosed as inferior wall myocardial infarction.
Keywords: Atypical myocardial infarction; Bed side Echocardiography; Cardiac regional wall motion abnormalities
A 32 year old female non diabetic, normotensive patient presents to hospital with severe burning type of pain in the abdomen-epigastric region, no radiation and associated with nausea, and no other aggravating or alleviating factors. She is a known case of acid peptic disease and is on treatment with proton pump inhibitors (pantaprazole) daily. No known drug allergies and denies usage of alcohol, illicit drug and smoking. No significant cardiac disease history in the family. All vital signs are in normal limits. Provisional diagnosis of acid peptic disease was established and treated with injection pantoprazole intravenous forty milligrams; in about half an hour, significant decrease in pain was noted. Electrocardiography (EKG) was done before discharge, showed nonspecific ST segment changes in II, III and AVF leads. Subsequently, bed side 2D Echo was done which showed regional wall motion abnormality. Later, diagnosis of Inferior wall MI was confirmed with raised troponin levels .
Myocardial ischemia, typically manifest with chest pain, with or without associated symptoms like shortness of breath, nausea, diaphoresis, palpitations, light headness and fatigue. While chest pain is considered the cardinal symptom of myocardial ischemia and ACS, some patients present with atypical symptoms and without chest pain. In a review by National Registry of Myocardial Infarction II; one-third of 430,000 patients with confirmed acute myocardial infarction (MI) had no chest pain at the time of presentation to the hospital . EKG is usually done if there are any of the cardiac symptoms. There are no fixed guidelines and recommendations by American heart Association (AHA) for doing an EKG for patients coming to the Emergency Department (ED) with non-cardiac complaints .
Most common presentation of the atypical MI mimics acid peptic disease, in which symptoms like epigastric pain, nausea are seen. Other atypical features less commonly seen are pain at non cardiac sites like neck, back, jaw, or head, followed by non-pain symptoms such as weakness, sweating, nausea, dyspnea, or cough. Women seem to be another subgroup with a greater likelihood of atypical presentation pattern .
Type 1 myocardial infarction is an acute athero-thrombotic coronary event while type 2 myocardial infarction is due to an imbalance between oxygen demand and supply other than CAD. Acute myocardial Infarction is diagnosed by detection of a rise and/or fall of cardiac troponin with at least one value above the 99th percentile with integration of at least one of the findings; symptoms of acute myocardial ischemia; new ischemic electrocardiographic (ECG) changes; development of pathological Q waves; Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology [5-7].
In a separate study of a cohort of 112,000 patients with MI, diagnosis was missed in 993 patients (0.9%) . Another study demonstrated that in a cohort of 41,000 patients, 11% initially had a non-diagnostic EKG. One third converted to STEMI by 30 minutes, 50% converted to STEMI by 45 minutes, and 75% converted by 90 minutes [9,10]. Absence of classic presentation, without risk factors and/or without significant EKG changes is the major cause of high incidence of unrecognized myocardial infarction. This leads to an increased mortality rate in patients with atypical presentation in comparison with classic presentation of AMI [11-13].
There is no standard protocol to be followed or a scoring system to help in diagnosis of these atypical presentations of MI of which acid peptic disease is most common. Hence, the evaluation of abdominal pain requires a good understanding of all the possible causes, and recognition of their typical patterns and clinical presentations. Apart from the regular laboratory studies subsequently, screening of these patients with bed side ultrasonography for cardiac regional wall motion abnormality should be done. A regional wall motion abnormality (RWMAs) develops within seconds in severe cardiac ischemia and can be visualized echocardiographically. These RWMA’s occur prior to the changes in EKG or even the development of clinical symptoms, which usually take few minutes. This can help to decrease the number of miss diagnosis of MI. Hence, evaluation of wall motion echocardiographically can be useful evaluation approach in noncardiac cases or high suspicion of ischemic heart disease is present .
- Anderson JL, Morrow DA (2017) Acute Myocardial Infarction. N Engl J Med 376: 2053-2064.
- Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, et al. (2000) Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 283: 3223-3229.
- 1998-2018 Mayo Foundation for medical Education and Research (MFMER). Electrocardiogram, USA.
- Culic V, Miric D, Eterovic D (2001) Correlation between symptomatology and site of acute myocardial infarction. Int J Cardiol 77: 163-168.
- Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, et al. (2018) Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 40: 237–269.
- Reichlin T, Twerenbold R, Reiter M, Steuer S, Bassetti S, et al. (2012) Introduction of high-sensitivity troponin assays: impact on myocardial infarction incidence and prognosis. Am J Med 125:1205.
- Angel López-Cuenca, Gómez-Molina M, Flores-Blanco PJ, Sánchez-Martínez M, García-Narbon A, et al. (2016) Comparison between type-2 and type-1 myocardial infarction: clinical features, treatment strategies and outcomes. J Geriatr Cardiol 13: 15-22.
- Moy E, Barrett M, Coffey R, Hines AL, Newman-Toker DE (2015) Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. Diagnosis (Berl) 2: 29-40.
- Riley RF, Newby LK, Don CW, Roe MT, Holmes DN, et al. (2013) Diagnostic time course, treatment, and in-hospital outcomes for patients with ST-segment elevation myocardial infarction presenting with non-diagnostic initial electrocardiogram: a report from the American Heart Association Mission: Lifeline program. Am Heart J 165: 50-56.
- Turnipsee SD, Trythall WS, Diercks DB, Laurin EG, Kirk JD, et al. (2009) Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 16: 495-499.
- Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, et al. (2004) Acute coronary syndromes without chest pain, an under diagnosed and undertreated high-risk group. Insights from the Global Registry of Acute Coronary Events. Chest 126: 461-469.
- Dorsh MF, Lawrance RA, Sapsford RJ, Durham N, Oldham J, et al. (2001) Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain. Heart 86 : 494-498.
- Culic V (2006) A typical presentation and unrecognized myocardial infarction. Eur Heart J 27: 2607.
- American College of Cardiology Foundation (2011) Role of echocardiography in acute myocardial infarction. J Am Coll Cardiol 57: 1126.