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.
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?
Appendicitis? (no, appendectomy was done years ago).
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.).
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).
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.
Imaging: Electrocardiograms, X-rays, CT scans
A Systematic Approach to Reading an EKG by Using 2 Mnemonics
Among patients with suspected ACS, hsTnI or cTnI determination 3 hours after admission may help to rule-out AMI - JAMA, 2011.