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• Overdiagnosis and typicality of symptoms in suspected myocardial infarction
  oscar,m jolobe
  Published on: 13 January 2020

• Published on: 13 January 2020

  Overdiagnosis and typicality of symptoms in suspected myocardial infarction

  • oscar,m jolobe, retired geriatrician manchester medical society

  Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...

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  Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic dilatation, pericardial effusion or tamponade, and aortic valve regurgitation, warranting urgent definitive aortic imaging or transfer to expert centres(9). In particular, in the latter study "integration of[focused TTE] with D-dimer provided an exceptionally safe and fairly efficient rule-out criterion for AAS(acute aortic syndrome"(9).
  I have no funding and no conflict of interest
  References
  (1) Greenslade JH., Sieben N., Parsonage WA
  Factors influencing physicians' estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome
  EMJ 2020;37:2-7
  (2) Swan D., Hitchen S., Klok FA., Thachill J
  The problem of underdiagnosis and overdiagnosis of pulmonary embolism
  Thrombosis Research 2019;177:122-129
  (3) Gimenez MR., Reiter M., Twerenbold R et al
  Sex-specific chest pain characteristics in early diagnosis of acute myocardial infarction
  JAMA Internal Medicine 2014;174:241-249
  (4) Kukla P., Diugopolski R., Krupa E et al
  How often pulmonary embolism mimics acute coronary syndrome?
  Kardiologia Polska 2011;69:235-240
  (5) Sandoval Y., Thgesen K
  Myocardial infarction Type 2 and myocardial injury
  Clinical Chemistry 2017;63:101-107
  (6) Villablanca PA., Vlismas PP., Aleksandrovich T et al
  Case report and systematic review of pulmonary embolism mimicking ST segment elevation myocardial infarction
  Vascular 2019;27:90-97
  (7) Amjad A., Ali A., Bashir A et al
  Chest pain with raised troponin, ECG changes bu normal coronary arteries
  BMJ case Reports 2014;doi:10.1136/bcr-2013-201975
  (8) Yen K-H., Chang H-C
  Massive pulmonary embolism with anterolateral ST segment elevation: electrocardiogram limitations and role of echocardiogram
  Am J Emerg Med 2008;26:632.e1-632.e3
  (9)Nazerian P., Mueller C., Vanni S et al
  Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes
  Eur Heart J 2019;40:1952-1960
  PS please ignore my previous Rapid Response. This one is the definitive version

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  Conflict of Interest:
  None declared.

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