ST elevation myocardial infarction differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

ST segment myocardial infarction must be differentiated from other conditions that cause ST elevation and chest pain.

Differential Diagnosis of Causes of ST Segment Elevation in the Absence of Myonecrosis

Acute epicardial artery occlusion by thrombus is certainly one cause of ST segment elevation, but other causes of ST segment elevation which are not associated with myonecrosis include the following:[1][2]

In Alphabetical Order

  • Aneurysm of the ventricle can result in persistent ST segment elevation that can be exacerbated with tachycardia.
  • Arrhythmogenic right ventricular cardiomyopathy
  • Balloon inflation in a coronary artery during percutaneous coronary intervention
  • Brugada syndrome
  • Transthoracic cardioversion
  • Coronary artery rupture during percutaneous coronary intervention
  • Early repolarization is a normal variant that can result in ST segment elevation. It is more common in males of younger age. The ST elevation is exacerbated by bradycardia.
  • Hyperkalemia known as the "dialyzable current of njury" hyperkalemia may cause hyperacute ECG changes due to changes in membrane polarity
  • Left bundle branch block is associated with ST segment elevation in those leads that are discordant to the QRS. Stated differently, if the QRS is predominantly of a negative deflection, it is normal to observe ST segment elevation in the same leads. The presence of ST elevation in leads where the QRS deflection is upright (concordance) may be a marker of myocardial injury.
  • Myopericarditis can cause injury to the subepicardial myocytes and ST segment elevation.
  • Myocarditis can cause injury to the subepicardial myocytes and ST segment elevation.
  • Pericardiocentesis when the needle comes into contact with the myocardium, there can be ST segment elevation reflecting local injury of the myocardium.
  • Pericarditis can cause injury to the subepicardial myocytes and ST elevation.
  • Pulmonary Embolism
  • Prinzmetal's angina is associated with ST segment elevation due to transient epicardial coronary artery spasm either in the absence or presence of atherosclerosis. If the condition persists long enough, myonecrosis can be observed.
  • Intracranial hemorrhage (stroke) can in some cases cause ST segment elevation due to direct myocyte injury from a hyperadrenergic stimulation emanating from the central nervous system.

Differential Diagnosis of Causes of ST Segment Elevation in the Presence of Myonecrosis (STEMI)

While plaque rupture is the most common cause of ST segment elevation MI, other conditions can cause ST elevation and myocardial necrosis. In order to expeditiously treat an alternate underlying cause of myonecrosis, it is important to rapidly identify conditions other than plaque rupture that may also cause ST elevation and myonecrosis. Indeed, the management of some of these conditions might be differ substantially from that of plaque rupture: cocaine induced STEMI would not be treated with beta-blockers, and myocardial contusion would not be treated with an antithrombin. These conditions include the following:

By Organ System

Cardiovascular Aortic dissection more often extends to occlude the ostium of the right coronary artery

Aortic stenosis can cause subendocardial ischemia and infarction if demand grossly exceeds supply

Chemical / poisoning Carbon monoxide poisoning
Dermatologic No underlying causes
Drug Side Effect Oral contraceptive pills, particularly among women who smoke

Anabolic steroids

Ear Nose Throat A recent upper respiratory tract infections has been associated with a 4.9 fold rise in the risk of MI
Endocrine Thyrotoxicosis
Environmental Blizzards and snow shoveling, and inhalation of fine particulate matter in areas with air pollution and high traffic have been identified as triggers of MI.
Gastroenterologic A heavy meal has been associated with a 4 fold rise in the risk of MI, and it is not clear if this is mediated by hyperadrenergic tone[3];
Genetic Familial hypercholesterolemia
Hematologic Disseminated intravascular coagulation (DIC)

Hypercoagulable states

Polycythemia vera

Thrombocytosis

Iatrogenic Epinephrine overdose

Sudden withdrawal of Beta blockers or nitrates

Infectious Disease A recent upper respiratory tract infections has been associated with a 4.9 fold rise in the risk of MI

Infectious endocarditis may STEMI as a result of embolization

Musculoskeletal / Ortho No underlying causes
Neurologic No underlying causes
Nutritional / Metabolic A heavy meal has been associated with a 4 fold rise in the risk of MI and it is not clear if this is mediated by hyperadrenergic tone[3];

Amyloidosis

Fabry disease

Homocystinuria

Mucopolysaccharidoses or Hurler disease

Pseudoxanthoma elasticum

Thiamine deficiency has been associated with ST elevation and myonecrosis [4] [5] [6]

Obstetric/Gynecologic Spontaneous coronary dissection in the setting of pregnancy
Oncologic Radiation therapy can accelerate atherosclerosis particularly in the distribution of the left anterior descending artery;
Opthalmologic No underlying causes
Overdose / Toxicity Cocaine ingestion which may result in direct myocyte injury due to an adrendergic surge, vasoconstriction of the microvasculature or plaque rupture and thrombus formation;

Marijuana ingestion has been identified as a trigger of MI.

Psychiatric Anger, anxiety, bereavement, work-related stress, earthquakes, bombings and other psychosocial stressors have been identified as triggers of MI, and it is not clear if the mechanism is plaque rupture or hyperadrenergic tone;

Stress cardiomyopathy or Broken heart syndrome causes ST segment elevation most often in the anterior precordium and is thought to be due to direct myocyte injury from a hyperadrenergic stimulation emanating from the central nervous system.

Pulmonary A recent upper respiratory tract infections has been associated with a 4.9 fold rise in the risk of MI
Renal / Electrolyte Homocystinuria
Rheum / Immune / Allergy Takayasus
Sexual Sexual activity has been identified as a trigger of MI
Trauma Both penetrating and non-penetrating trauma to the heart or myocardial contusion, commotio cordis can be associated with ST elevation and myonecrosis.
Urologic No underlying causes
Miscellaneous Hypotension particularly if it is prolonged

Complete Differential Diagnosis of Chest Pain

ST elevation MI is one of several life threatening causes of chest pain that must be distinguished from each other.

5 Life Threatening Diseases to Exclude Immediately

The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is:[7]

Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders

Thorough history including: onset, duration, type of pain, location, exacerbating factors, alleviating factors, and radiation. Risk factors for coronary artery disease: family history, smoking, hyperlipidemia, and diabetes.

Clinical Features of Different Conditions Presenting with Acute Chest Discomfort

CARDIOVASCULAR

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
Stable Angina Sudden (acute) 2-10 minutes Heaviness, pressure, tightness, squeezing, burning (Levine's sign) Retrosternal Exertion, emotions, cold Rest, sublingual nitroglycerine (within minutes) Radiation to neck, jaw, shoulders, or arms (commonly on left) Sweating, nausea, palpitations, dizziness, shortness of breath, sense of impending doom
Unstable Angina Acute 10-20 minutes Same as stable angina but often more severe Same as stable angina Same as stable angina but occurs with lower levels of exertion & rest Same as stable angina Same as stable angina Same as stable angina
Myocardial Infarction Acute Commonly > 20 minutes Same as stable angina but often more severe Same as stable angina Same as stable angina but occurs with lower levels of exertion & rest Usually unrelieved by nitroglycerine and rest Same as stable angina Same as stable angina
Aortic Stenosis Acute, recurrent episodes of angina Same as stable angina Same as stable angina Same as stable angina Same as stable angina Same as stable angina Same as stable angina Not specific
Aortic Dissection Sudden severe progressive pain (common) or chronic (rare) Variable Tearing, ripping sensation, knife like Depends on area of dissection Variable Unrelenting pain, unrelieved by nitroglycerine and rest Radiating to back, between shoulder blades (dissection in ascending aorta) Trauma, Surgical manipulation, pregnancy, hypertension, connective tissue disease like marfan's syndrome (cystic medial degeneration)
Pericarditis Acute or subacute May last for hours to days Sharp, localized Retrosternal Increases with coughing, deep breathing, supine position Relieved by sitting up and leaning forward Radiation to shoulder, neck, back abdomen Not specific

PULMONARY

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
Pulmonary Embolism Acute May last minutes to hours Sharp, or knifelike pleuritic pain Localized to side of lesion Increased on respiratory movements, deep breathing or cough Not specific Not specific Dyspnea, tachypnea, palpitation, and light headedness, hemoptysis, or a history of venous thromboembolism or coagulation abnormalities.
Spontaneous Pneumothorax Acute May last minutes to hours Sharp, localized pleuritic Localized to side of lesion Not specific Not specific Not specific Dyspnea, decreased breath sounds on involved side
Pleuritis Acute, subacute, chronic May last minutes to hours Sharp, localized pleuritic Localized to side of lesion Increased on respiratory movements, deep breathing or cough Not specific Not specific Dyspnea, cough, fever
Pulmonary Hypertension Acute, subacute, chronic Variable Pressure like Substernal Not specific Not specific Not specific Dyspnea, symptoms of right heart failure (edema

GASTROINTESTINAL

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
GERD, Peptic Ulcer Acute Minutes to hours (gastroesophageal reflux), prolonged (peptic ulcer) Burning Substernal, epigastric Increases on alcohol, aspirin, post meal lying down, morning, empty stomach Relieves on antacid, food Not specific Not specific
Esophageal Spasm Acute Minutes to hours Burning, pressure Retrosternal Not specific Relieved by sublingual nitroglycerine Not specific Not specific (closely mimic angina)
Cholelithiasis Acute, subacute Minutes to hours Burning, colicky Right upper abdomen, substernal, epigastric Increases post meal, fatty food, 1-2 hours post meal Analgesics Not specific Not specific

MISCELLANEOUS

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
Musculo-skeletal Pain Acute, subacute Variable Pressure, aching Localized to involved area Increases by movement and pressure on involved area Analgesics Not specific Not specific
Psychotic Conditions Acute, subacute, chronic Variable Variable Variable Variable Not specific Not specific History of depression, Panic attacks, Agrophobia

By Organ System

Cardiovascular Acute Aortic DissectionAcute Coronary Syndrome • (unstable angina) • (non ST elevation MI) • (ST elevation MI) • Aortic AneurysmAortic StenosisArryhthmiasBland-White-Garland SyndromeChronic Stable AnginaCor pulmonaleCoronary Heart Disease Dressler's syndrome (postpericardiotomy)Hypertrophic CardiomyopathyMitral valve prolapseMyocardial infarctionMyocarditisPericardial tamponadePericarditisTakotsubos cardiomyopathyStress cardiomyopathy
Chemical / poisoning No underlying causes
Dermatologic Herpes zoster
Drug Side Effect Drugs to treat migraine headache
Ear Nose Throat Retropharyngeal abscess
Endocrine Acromegaly
Environmental No underlying causes
Gastroenterologic AchalasiaAbdominal distensionBarret’s esophagusCarcinomaCholecystitisCholelithiasisDiverticulitisDuodenitisEsophageal ruptureEsophageal spasmEsophagitisForeign bodyGastritisGastroesophageal reflux (GERD) • Hiatus HerniaImpacted stoneLiver abscessMallory-Weiss SyndromeNeoplasmNutcracker's esophagusPancreatitisPeptic ulcer diseasePerforated ulcerPlummer-Vinson SyndromePneumoperitoneumSplenic enlargementSplenic infarction • Subdiaphragmatic abcsess • Subphrenic abscessWhipple's Disease
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease Bornholm diseaseHepatitisHIV infectionHerpes Zoster
Musculoskeletal / Ortho Bechterew's DiseaseBone tumor • Chest wall injuries • Chest wall pain syndrome • Costochondritis • Chosto condral tendinitis • Chosto sternal tendinitis • Tietze's syndrome • CS/TS osteochondrosis • FibromyalgiaFractured ribIntercostal muscle spasm • Interstitial fibrosis • Intercostal neuralgiaMuscle strain or spasm • Myofascial pain • MyostitisNeuritisRadiculitisPeriostitisPrecordial catch syndromeShoulder bursitisShoulder tendinitisSoft tissue sarcoma or tumor • Sternoclavicular arthritis • Strain of pectoralis muscle • Thoracic Outlet SyndromeTrauma • Vertebrogenic thoracic pain
Neurologic Tabes dorsalis
Nutritional / Metabolic No underlying causes
Oncologic Liver cancerMesotheliomaMetastatic tumorNeurofibromaPheochromocytoma
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric Anxiety disordersAffective disorders (e.g., depression) • Da costa's syndrome • Thought disorders (e.g., fixed delusions) • Hyperventilation syndromeHypochondriaFactitious disorders (e.g. Münchausen syndromeFabricated or induced illness • Hospital addiction syndrome) • Panic attackSomatoform disordersSomatization disorder
Pulmonary AsthmaBronchial carcinomaBronchiectasisBronchogenic carcinomaCarcinomatousPleural EffusionChronic Obstructive Pulmonary Disease (COPD) • EmpyemaHemothoraxLung AbscessLung CancerLymphomaMediastinitisPleuritisPleurodyniaPneumomediastinumPneumoniaPneumothoraxPulmonary EmbolismPulmonary InfarctionTension pneumothoraxThymoma • Tracheoesophageal abscess • Tuberculosis
Renal / Electrolyte No underlying causes
Rheum / Immune / Allergy No underlying causes
Trauma No underlying causes
Miscellaneous • Collagen vascular disease with pleuritis • Conn's Syndrome • Degenerative changes of cervical spine • Familial Mediterranean FeverPeritonitisPott's Disease • Xyphodenia

By Alphabetical Order

References

  1. Wang K, Asinger RW, Marriott HJ (November 2003). "ST-segment elevation in conditions other than acute myocardial infarction". N. Engl. J. Med. 349 (22): 2128–35. doi:10.1056/NEJMra022580. PMID 14645641.
  2. Ako J, Honda Y, Fitzgerald PJ (March 2004). "Conditions associated with ST-segment elevation". N. Engl. J. Med. 350 (11): 1152–5; author reply 1152–5. doi:10.1056/NEJM200403113501118. PMID 15014192.
  3. 3.0 3.1 Lipovetzky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS (December 2004). "Heavy meals as a trigger for a first event of the acute coronary syndrome: a case-crossover study". Isr. Med. Assoc. J. 6 (12): 728–31. PMID 15609883.
  4. Kawano H, Koide Y, Toda G, Yano K (June 2005). "ST-segment elevation of electrocardiogram in a patient with Shoshin beriberi". Intern. Med. 44 (6): 578–85. PMID 16020883.
  5. Hundley JM, Ashburn LL, Sebrell WH. The electrocardiogram in chronic thiamine deficiency in rats. Am J Physiol 144: 404–414, 1954.
  6. Read DH, Harrington DD (June 1981). "Experimentally induced thiamine deficiency in beagle dogs: clinical observations". Am. J. Vet. Res. 42 (6): 984–91. PMID 7197132.
  7. Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (July 1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal 17 (7): 1028–34. PMID 8809520. Retrieved on 2012-05-02.

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