Acute Myocardial Infarction (MI) Which Presented with Right Lower Quadrant (RLQ) Abdominal Pain

Author: V. Dimov, M.D., Cleveland Clinic
Reviewer: A. Aneja, M.D., Cleveland Clinic

An 81-year-old African American female (AAF) with a past medical history (PMH) of hypertension (HTN), diabetes type 2 (DM2), coronary artery disease status post myocardial infarction (CAD S/P MI) 5 years ago, and chronic abdominal pain for 2 years without a clear reason, was admitted to the hospital with a worsening of the same abdominal pain for 2-3 days.

No chest pain (CP) or shortness of breath (SOB). She complains of (c/o) nausea and vomiting.

Physical examination

38.8 C-16/min-78 bpm-210/100 mm/Hg
Abdomen: RLQ tenderness, no rebound, soft, +BS.
The rest of the examination was not remarkable.

What laboratory workup would you suggest?

CBCD, CMP, Amylase, Lipase, UA were all normal.
KUB was nonspecific.
CT of abdomen showed a dilated stomach, stable 3.6 cm AAA (the same size as 2 yrs ago) and old renal cysts.

Patient was started on IVF, pain meds and Zosyn for T* 38.3. Blood cx were taken.

What is the most likely diagnosis?

Diverticulitis?
Appendicitis? (no, appendectomy was done years ago).
DM Gastroparesis?
Gastroenteritis?

Do not make the list too long. One experienced internist once said that a long list of differentials is simply a list of wrong diagnoses (Adnan Tahir, M.D.).

What happened?

ECG on admission showed deep Qs waves in the inferior leads - probably an old MI. Cardiac enzymes x 1 were ordered.


ECG - before the MI (left). Second ECG showing acute changes of NSTEMI (right) (click to enlarge the images).


Cardiac enzymes were positive, showing troponin elevation (click to enlarge the images).

Final diagnosis

Non-ST elevation myocardial infarction (Non-STEMI).

The catheterization showed a 99% occlusion of one of the branches of the circumflex artery (Cx). Two stents were placed. The right coronary artery (RCA) had a 90% proximal stenosis but both stent placement and PTCA were unsuccessful. The patient was scheduled for a repeated catheterization for stent placement in RCA within 2-3 weeks.


The cardiologist drew a diagram of the stent placement in the Cx artery (click to enlarge the images).

What did we learn from this case?

Always keep the possibility of an acute myocardial infarction (AMI) in patients with risk factors, even with atypical symptoms. MI can be completely painless in diabetics and women. You do not need the symptoms of chest pain (CP) to diagnose an MI.

Is it true that there is a "cardioptosis of old age"?

It means that with age the heart migrates down towards the abdomen. Consequently you have to rule out MI even in patients with abdominal pain. No, not really. This is a just a lame cardilogy joke...

In this case though, the RLQ pain was not related to the MI.

References

Imaging: Electrocardiograms, X-rays, CT scans
A Systematic Approach to Reading an EKG by Using 2 Mnemonics

Related reading

Among patients with suspected ACS, hsTnI or cTnI determination 3 hours after admission may help to rule-out AMI - JAMA, 2011.

Published: 04/11/2006
Updated: 06/22/2009

9 comments:

  1. Interesting case. Would've loved to read about the initial management of this patient - what was done in the ED and then by the internist. Nonetheless, thank you!

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  2. i dont understand,you can give me the treatment of myocardial infarction?

    thank you!

    my email:toiditimtoi15102002@yahoo.com

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  3. Regarding initial management of CP r/o AMI and suspected MI, please have a look here:

    Admission Note for Chest Pain (CP)
    http://note3.blogspot.com/2005/01/admission-note-for-cp.html

    Admission Note for Chest Pain (ICU Management)
    http://note3.blogspot.com/2005/01/admission-note-for-cp-icu.html

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  4. M. Valendo, RN4/29/2010 9:01 PM

    This case is a great learning point. As the manager of an Emergency Department, we've put an emphasis on atypical presentations of Myocardial Infarction into our annual RN competencies. As you stated in the case review, this patient had several things going for her that could lead to an atypical presentation: elderly, female, diabetic.

    The history of cardiac disease and nausea would certainly have promtped me to get a quick ECG on this patient. These are definitely the types of patients you want to be careful with, and not just send back to the waiting room.

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  5. Yep, you never know nowadays...

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  6. I am the charge RN of an observation unit with primarily chest pain patients.I enjoyed reading this article and shared it with my coworkers.I didn't know a MI can be painless in diabetics and women.I knew the symptoms present very different in women vs. men. What was the cause of the abd pain?

    PS. Thanks for this educational avenue

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  7. only because of the overlap between the visceral Ns carrying sensation from the heart from receptors at the BV and the Ns of the anterior chest so any pain at the heart sensed at anterior chest may be up to the lower jaw and down to the epigastrum (NOT ABOVE JAW OR BELOW EPIGASRUM)

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  8. following the abdominal pain, I think she must have another GIT disease not relating to the already existing disease. Or she is suffering from DIVERTICULITIS that must have arose from diverticulosis (developed many months ago due to over fatty food, usually asymptomatic when it has not become diverticulitis).

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  9. I think there are much evidential findings to say that this is DIVERTICULITIS, the temperature is high (38.8C),it is a characteristic of bacteria/inflammatory disease, so it is not GASTROPARESIS. There is tenderness of Right Lower Quadrant, since she had appendectomy, it cannot be appendicitis, and we know for sure DIVERTCULITIS is of colon not of stomach or small intestines, so it can not be Gastroenteritis. With these data, I conclude in my own understanding that it is DIVERTICULITIS.

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