Case history
Case history
A 69-year-old man develops worsening substernal chest pressure after shoveling 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 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. Three doses of sublingual nitroglycerin provide little relief.
Other presentations
Presentations of myocardial infarction (MI) can be diverse. Some patients do not have any chest discomfort, whereas others may experience classic "crushing" or severe pain. It is important to recognize that nonclassic presentations such as dyspnea, syncope, palpitations, isolated nausea/vomiting, abdominal pain, and fatigue can indicate acute coronary syndrome. These presentations are more common in women, older people, people with diabetes, those with chronic kidney disease, and cardiac transplant recipients. A feeling of indigestion may be the only symptom and occurs more often with inferior wall MI. Highly specific presentations include substernal pressure/discomfort, which may radiate to the arm, neck, and shoulder, associated with diaphoresis and anxiety.[2] Some patients present with jaw, neck, ear, 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 nitroglycerin or physical rest. A sharp, stabbing pain or pain reproducible on palpation does not exclude acute coronary syndrome.[2]
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