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Chest Pain, ST Elevation, and Increasing Troponin: Is It Really Myocardial Infarction? FREE TO VIEW

Kovid Trivedi*, MD; Pranay Trivedi, MBBS; Hasnain Bawaadam, MD; Nitesh Jain, MD; Aman Sethi, MD; Rashid Nadeem, MD
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Chicago Medical School/Rosalind Franklin University of Medicine & Science, North Chicago, IL

Chest. 2012;142(4_MeetingAbstracts):353A. doi:10.1378/chest.1390372
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SESSION TYPE: Critical Care Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Chest pain is an important symptom of myocardial infarction (MI) and this is why it alerts the health care team. AHA guidelines say that the presence of any 2 of the 3 cardinal features of acute coronary syndrome, i.e. chest pain, EKG changes and positive & rising cardiac enzymes, are enough to diagnose MI. But a false diagnosis of MI may lead the patient to unnecessary invasive procedures that might be associated with morbidity and mortality.

CASE PRESENTATION: 40 year old female with history of diabetes mellitus presented to the ED with 10/10 left-sided chest pain radiating to left arm with numbness of left arm and palpitations & anxiety. The pain increased on deep inspiration. Physical examination revealed over-weight female with no other significant positive finding. Troponin I and CK-MB were elevated. 12 lead EKG showed ST segment elevation in leads I, II, avR, avL & V2-V6 with no reciprocal changes. Patient had a history of URI 1 week back. Based on this scenario, she was diagnosed with acute pericarditis. Repeat troponin levels showed rise. Diagnoses of myocarditis or myocardial infarction were also considered at this point. Considering the risk factors (weight, diabetes mellitus, ST elevation, Troponin rise) and unavailability of a catheterization laboratory at our hospital, it was decided to transfer the patient for PCI. At the other hospital, trans-thoracic echocardiogram done prior to catheterization revealed no cardiac wall motion abnormalities that might be present due to MI. It was decided not to proceed with catheterization but instead manage the patient conservatively due to risk-benefit analysis of the procedure and more likelihood of acute pericarditis. The patient improved with conservative management. Patient was followed clinically and with serial TTE.

DISCUSSION: Although classical physical exam findings are diagnostic of acute pericarditis, ST segment elevation with increasing cardiac biomarker levels create a suspicion of MI. Diffuse ST segment elevation is one of the most important diagnostic characteristics of acute pericarditis. J point elevation and diffuse ST elevation help in differentiating MI from pericarditis. Our patient was unique that she didn't have pericardial rub and didn't have ST elevation in all the leads, and this might otherwise been suggestive of massive anterior wall MI. Troponin and CK-MB elevation were found in 38 patients in a study involving 118 patients (32%) of acute pericarditis. These patients are supposed to have myopericarditis. The 90 minute door-to-balloon window prompts us to take the patient for PCI in case of ST elevation and Troponin elevation.

CONCLUSIONS: Cardiac catheterization is an invasive procedure that is associated with significant risks and risk-benefit ratio should always be analyzed before sending the patient for it.

1) Imazio M, Demichelis B, Cecchi E, et al. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol 2003; 42:2144

DISCLOSURE: The following authors have nothing to disclose: Kovid Trivedi, Pranay Trivedi, Hasnain Bawaadam, Nitesh Jain, Aman Sethi, Rashid Nadeem

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Chicago Medical School/Rosalind Franklin University of Medicine & Science, North Chicago, IL




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