What Can be Mistaken for Myocardial Infarction?

R.K. has been experiencing symptoms similar to that of myocardial infarction. However, her labs came back normal (which will be discussed later) and it suggests there has been no damage to the heart and that angina pectoris is the reason related to coronary artery disease. The cause of this pain is inadequate blood flow in the coronary arteries which causes a decreased oxygen supply when there is an increased demand on the heart for oxygen. Usually caused by atherosclerotic diseases, heart diseases that harden and narrow the arteries around the heart, angina presents itself when there is an obstruction of at least one major coronary artery (Brunner, 2014).

There are 5 types of angina; stable angina, unstable angina, intractable (refractory) angina, variant (Prinzmetal’s) angina, and silent ischemia.

Stable angina is predictable and can be expected to follow after some form of exertion and is relieved with rest and/or with the medication, nitroglycerin. Unstable angina is diagnosed when angina symptoms start increasing in frequency and severity; unstable angina may not be relieved through rest or with the use of nitroglycerin (Brunner, 2014).

Intractable angina is when this pain severely incapacitates the person. Often called Prinzmental’s angina or Variant angina is thought to be caused by vasospasms in the coronary arteries and the person experiences pain while resting and with EKG shows a reversible ST-segment elevation (Brunner, 2014). Silent ischemia is when the person reports no pain at all but there is evidence on an ECG strip during a stress test or other cardiac tests.

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With all of these types, several factors are associated with chest pain.

Physical exertion is what often triggers typical, angina pain because of the increased oxygen demand on the heart. Exposure to cold may trigger angina pain because of the body’s vasoconstriction response to maintain body temperature which causes an increase in blood pressure that then leads to the increased oxygen demand of the heart. With the major holidays around the corner, many people experience angina pain because of eating heavy amounts of food. All this food means there is a demand for increased blood flow to aid with the digestion process and this reduces blood flow to the heart and can induce anginal pain. Another factor is stress and emotional situations; these cause the body to release catecholamines and other hormones that increase blood pressure, heart rate, and increased myocardial workload (Brunner, 2018).

Clinical Presentation

As mentioned above we know R.K came in for heavy substernal pressure and epigastric distress. There are other manifestations of angina that may also be presented. Many of these manifestations are present for another diagnosis such as a myocardial infarction. Chest pain is an obvious indicator of heart issues. This pain may have sensations described as squeezing, pressure, burning, or fullness that is located deep in the chest. This pain may also radiate down the patient’s arm, neck, shoulder, or back. The patient may also be sweating, dizzy, lightheaded, or may have nausea and vomiting. Dizziness and lightheadedness may be caused by shortness of breath often experienced by patients with chest pain. Fatigue and weakness are seen in many chest pain cases. Patients also report a feeling of doom. Women may exhibit these other presentations rather than an initial feeling of chest pain but may have a stabbing feeling in their chest.

Diagnostic Studies

To determine the cause of R. K’s chest pain several diagnostics are utilized. A twelve-lead ECG will be taken to determine if R.K has had an MI. This can also show any ischemic changes to the heart and in what part and whether she is having any irregular rhythms. A Chest x-ray is taken to show whether any structural defects may be contributing to her chest pain. Continuous pulse oximetry is used to help determine if her chest pain may be caused by a respiratory issue. Cardiac enzymes (creatine phosphokinase, troponin T/I, myoglobin) are drawn to determine whether she’s had a myocardial infarction and if she has, they would be elevated. A complete blood count with differential is taken to get for infection or anemia. A comprehensive metabolic panel is drawn for electrolyte imbalances, and kidney function and can also check her lipid panel. A D-dimer test may be given to rule out pulmonary embolus. Coagulation studies (PT/INR/PTT) may be taken to check for any of these disorders. Invasive procedures such as coronary angiography or cardiac catheterization may be performed and treatment is given immediately for any encountered issues.

Medical Management & Treatments

The goal of medical management is to decrease the oxygen demand of the heart and increase the oxygen supply to the heart. These goals can be met through pharmacologic means, by controlling risk factors we previously discussed, and through reperfusion procedures (CABG and percutaneous transluminal coronary angioplasty) to restore the heart’s blood supply (Brunner, cite). Risk factors can be controlled through various lifestyle changes such as smoking cessation, maintaining a healthy weight, eating a well-balanced diet, exercising, learning relaxation techniques to help manage stress, avoiding triggers that cause chest pain, and by a person taking their medications as prescribed. Oxygen therapy is also initiated to help increase the amount of oxygen that can be delivered to the heart and decrease pain at the onset of chest pain. Pharmacologic therapies include the use of nitroglycerin, beta-blockers, calcium channel blockers, antiplatelet medications (i.e. aspirin), and anticoagulants (Thadani, 2016).

Nitroglycerin is a standard treatment for angina pectoris both prehospital and in-hospital treatments (P. Brian Savino, Karl A. Sporer, etc, 2015). This medication vasodilates veins and improves blood flow to the heart and reduces the oxygen demand for the heart. Nitroglycerin can be taken at home when a person is participating in an activity known to cause chest pain and if chest pain is unrelieved after 3 tablets taken 5 minutes apart medical attention should be sought. Beta-blockers reduce the beta-adrenergic sympathetic stimulation of the heart which reduces heart rate, and blood pressure and increases the contractility of the myocardium (Brunner, 2014). This reduces myocardial oxygen consumption. Calcium channel blockers, such as Norvasc and Cardizem, may be given to patients that do not respond to beta-blocker treatment. Calcium channel blockers have negative inotropic effects, these effects decrease the conduction of the heart thereby reducing heart rate and also decreasing the strength of the myocardial contraction (Brunner, 2014). A major side effect to monitor for when using nitroglycerin, beta-blockers, and calcium channel blockers is hypotension.

Another part of the pharmacological management of chest pain is by taking antiplatelet and anticoagulant medication. Prehospital management of chest pain (and in the hospital too) includes the use of aspirin. Aspirin prevents platelet aggregation and is given and suggested in all settings at the beginning of chest pain (unless an allergy or GI is bleeding (based on hospital protocol) in which case the use of aspirin is contraindicated) because of the possibility of the chest pain being related to myocardial infarction (cite). Heparin is an anticoagulant used to prevent new blood clots from forming and reduces the chance of rebound ischemic events from happening (cite). With anticoagulation therapy, it is important to put the patient on bleeding precautions.