Case history
Case history
A 69-year-old man develops worsening substernal chest pressure after shovelling snow in the morning before work. He tells his wife he feels a squeezing pain that is radiating to his jaw and left shoulder. He appears anxious and his wife calls for an ambulance, as he is distressed and sweating profusely. Past medical history is significant for hypertension and he has been told by his doctor that he has borderline diabetes. On examination in the accident and emergency department he is very anxious and diaphoretic. His heart rate is 112 bpm and blood pressure is 159/93 mmHg. The ECG is significant for ST depression in the anterior leads.
Other presentations
Presentations of myocardial infarction can be diverse. Some patients do not have any chest discomfort, whereas others may experience classic 'crushing' or severe pain. It is important to recognise that presentations where chest pain is not the predominant feature (chest-pain equivalent symptoms) such as epigastric pain, indigestion-like symptoms, isolated dyspnoea, or syncope can indicate acute coronary syndrome. These non-characteristic presentations are more common in women, older people, and people with diabetes, chronic kidney disease, or dementia. A feeling of indigestion may be the only symptom and occurs more often with inferior wall myocardial infarction. Highly specific presentations include substernal pressure/discomfort, which may radiate to the arm, neck, and shoulder, associated with diaphoresis.[1] Some patients present with jaw, neck, arm, or epigastric pain only. These symptoms should be considered equivalent to angina if they are clearly related to stress or exertion, or are quickly relieved by physical rest. A sharp, stabbing pain or pain reproducible on palpation does not exclude acute coronary syndrome.[1]
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