The importance of the differential diagnosis in an acute myocardial infarction presentation

Introduction: ST-Elevation Myocardial Infarction (STEMI) it is a type of acute coronary syndrome which implies transmural necrosis of a myocardial area and has the ECG equivalent of a ST-segment elevation in the corresponding leads. It is a severe condition and the mortality rate is very high without a quick diagnosis and an adequate treatment. Despite of apparently sim-ple diagnosis, there are many acute pathologies that can simulate ST-elevation myocardial infarction.

Case review: A 42 year-old male patient, smoker, with known dyslipidemia, presents to the emergency room with inferior and lateral STEMI – retrosternal pain that radiates to the left arm and started at rest 6 hours before admission. He also describes vegetative pheno-mena and had two similar self-limiting episodes in the last two weeks. The patient has no significant medical history. Physical examination: BP 130/60 mmHg, PR 76 per minute, regular, no cardiac murmur, no signs of pulmonary or systemic edema, with symmetrically bilateral peripheral pulse. Biological profile: increased levels of cardiac enzymes at admission (hsTnI 7109 ng/ ml), inflammatory syndrome (CRP 70 mg/dl). ECG: Sinus rhythm, PR 66 per minute, ST-segment elevation in V5-V6, DII, DIII, AVF leads. Transthoracic echo-cardiography: preserved left ventricle ejection fraction (LVEF 55%), basal septal hypokinesia, no significant valve disease, no pericardial effusion. Emergency co-ronarography: normal epicardial coronary arteries. He received dual antiplatelet therapy, parenteral anticoa-gulant, beta blocker, angiotensin-converting enzyme inhibitor (ACEI) and statin. After a careful anamnesis the patient mentions that he had two episodes of shivers and fever in the last 1-2 weeks, high rate palpitations, dyspnea and severe anxiety. He denies the presence of acute respiratory infections or diarrhea. The differen-tial diagnosis between myocardial infarction with no-nobstructive coronary arteries (MINOCA) and acute myocarditis is considered, and thus a cardiac MRI was performed. The images show a preserved left ventricu-lar ejection function and no left ventricular dilation, but diffuse late myocardial gadolinium enhancement which suggests inflammation of myocardial tissue and edema, which is associated with the diagnosis of acute myocarditis. The treatment is adjusted to one antiplate-let drug, beta blocker, angiotensin-converting enzyme inhibitor, aldosterone inhibitor and statin. During ho-spitalization, the patient had a favorable clinical course and was hemodynamically and electrically stable.

Case specific features: patient with multiple major car-diovascular risk factors and high probability of athe-rosclerotic coronary artery disease presents at emer-gency room with acute myocarditis that imitates inferi-or and lateral STEMI.

Conclusions: The thorough anamnesis, differential di-agnosis and modern imaging techniques are crucial in some cases to clarify the diagnosis, to initiate a proper treatment and to prevent irreversible complications that can occur during the evolution of disease.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
ESC search engine
CODE: 379
CME Credits: 10 (Romanian College of Physicians)
This work is licensed under a Creative Commons Attribution 4.0 International License.