Atypical manifestations in acute myocardial infarction. Does it matter?

Author(s): Camelia Nicolae

 Abstract

Statement of the problem. According to the latest guidelines (1,2), the leading symptom that initiates the diagnostic and therapeutic algorithm in patients with myocardial infarction (MI) is chest pain. Depending on the presence of pain and electrocardiographic changes, MI are classified in MI with persistent ST elevation ( STEMI) and  without persistent ST elevation (NSTEMI).The most common atypical clinical manifestation in MI  are :heart failure, atypical location of the pain, central nervous system manifestation stroke-like, syncope, apprehension ,acute indigestion (3) .Methodology and theoretical orientation. Anginal pain is considered to be the typical clinical manifestation in MI but a significant percentage of patients experience atypical manifestations. These atypical signs can be clinical, electrocardiographic, and combined. Atypical  electrocardiographic manifestations are: left and right bundle branch block, ventricular paced rhythm  that  masks electrical signs of ischemia, posterior  MI, Avr ST elevation(2) .Clinical trials at  the beginning of the revascularization era in MI(4) but  also the most recent, describe that the most common atypical manifestations are dyspnea, diaphoresis, nausea and vomiting, syncope. The Grace (5) study has shown that a quarter of patients with atypical manifestation at presentation are undiagnosed. Also, patients with atypical manifestation(6,7,8) exhibit a more unfavorable outcome during hospitalization than those with typical signs as follows: acute pulmonary edema (33% vs 14.9%) ,cardiogenic shock(8.6% vs 3.8%), acute kidney failure (10.3% vs 3.4%) and death (13% vs 4.3%).The main prediction factors for atypical manifestation,  in a recently  published study(9) are following :Killip class heart  failure, NSTEMI, age, diabetes  mellitus.

Conclusions and significance; Patients with MI and atypical manifestations have a higher mortality, regardless of type of infarction. The access of these patients to admission to a coronary care department, revascularization procedures and subsequent rehabilitation and monitoring by a cardiologist is much lower.

 

Recent Publications

1.2015 ESC Guidelines for the management of acute coronary syndromes in patients

presenting without persistent ST-segment elevation. European Heart Journal (2016) 37, 267–315.

2.2017 ESC Guidelines for the management of acute myocardial infarction in patients

presenting with ST-segment elevation. European Heart Journal (2017) 00, 1–66

3 Braunwald”s Heart Disease. Tenth Edition;pg. 1085.

 

4.M F Dorsch, R A Lawrance, R J Sapsford, N Durham, J Oldham, D C Greenwood,

B M Jackson, C Morrell,M B Robinson, A S Hall, for the EMMACE Study GroupPoor prognosis of patients presenting with  symptomatic myocardial infarction but without

chest pain. Heart 2001; 86:494–498.

5.David Brieger, Kim A. Eagle, Shaun G. Goodman, P. Gabriel Steg, Andrzej Budaj, Kami White, Gilles Montale scot, for the GRACE Investigators. Acute Coronary Syndromes Without Chest Pain, An Underdiagnosed and Undertreated High-Risk Group. Insights from The Global Registry of Acute Coronary Events. Chest. 2004 Aug;126(2):461-9

Biography:

Camelia Nicolae is an Associate Professor Carol Davila University of Medicine and Pharmacy, Romania

2^nd Edition of International Conference on Hypertension and Cardiovascular Diseases webinar, October 05-06, 2020.

 

Abstract Citation:

Camelia Nicolae is an Associate Professor Carol Davila University of Medicine and Pharmacy, Romania – Atypical manifestations in acute myocardial infarction. Does it matter? Hypertension & CVD 2020, 2^nd Edition of International Conference on Hypertension and Cardiovascular Diseases, webinar October 05-06, 2020

PDF