Determinants of clinical presentation on outcomes in older patients with myocardial infarction

Unusual and very rare presentation of wrist pain in a man with acute anterior myocardial infarction, a case report and literature of review

BACKGROUND

As acute myocardial infarction (AMI) prevalence is increasing because of lifestyle changes, the incidence of atypical symptoms in acute coronary syndrome (ACS) is rising and making misdiagnosing of this fatal event more probable. To better approach the patients with atypical symptoms, we tend to present a rare case of AMI with wrist pain.

CASE REPORT

A 41-year-old man presented to the emergency room (ER) with severe both-hand wrist pain and mild epigastric pain. His electrocardiogram (ECG) showed anterior ST-elevation myocardial infarction (MI) with an ejection fraction of 35-40%. His angiography showed severe left anterior descending artery (LAD), and first obtuse marginal artery (OM1) artery stenosis. He underwent Primary percutaneous coronary intervention (PCI). The patient recovered without serious complications and was discharged the day after PCI.

DISCUSSION

In this rare case of AMI with wrist pain, it is important to know that atypical symptoms can be present at various levels of symptoms, which prevents future misdiagnosis.

Navigating Diagnostic Challenges in Acute Coronary Syndrome: A Case of Bezold-Jarisch Reflex and Wellens Pattern

Acute coronary syndrome (ACS) presents significant diagnostic challenges, particularly in cases with atypical presentations and complex clinical scenarios. Here, we describe the case of a 59-year-old man who presented with presyncope, bradycardia, hypotension, and later syncope, attributed to the Bezold-Jarisch reflex. Electrocardiographic findings suggested both inferior and anterior wall infarction, with dynamic changes in T-wave morphology further complicating the diagnostic process. Despite a type A Wellens' pattern indicating critical stenosis in the proximal left anterior descending (LAD) artery, coronary angiography revealed a complete thrombotic lesion in the proximal right coronary artery (RCA), necessitating urgent intervention. Despite the Wellens pattern indicating LAD involvement, RCA revascularization took precedence due to immediate thrombotic risk. This case underscores the diagnostic challenges associated with conflicting clinical manifestations in ACS and highlights the importance of individualized management strategies integrating advanced diagnostic modalities to optimize outcomes. Understanding the interplay of complex clinical presentations and employing a nuanced approach to management are crucial in effectively navigating ACS scenarios.

Unsuspected finding of right coronary artery occlusion on nongated CT chest

Myocardial infarction (MI) is the main cause of morbidity and mortality globally. This occurs due to occlusion of the coronary artery resulting in ischemia of the cardiac muscles. Typical symptoms include chest pain and discomfort. However, there are atypical symptoms including, but not limited to epigastric pain, nausea, and syncope. Such atypical symptoms upon presentation to the emergency department make it rather easy to overlook a potential MI. We present a case of a 70-year-old woman who had a delayed presentation to the emergency department with epigastric pain, nausea, and syncope. A nongated CT scan of the chest was utilized to rule out an aortic dissection. Interestingly, an unsuspected finding of a right coronary artery occlusion was detected instead. The patient underwent coronary artery stenting and was discharged a week later with a beta-blocker, dual antiplatelet therapy, a diuretic, and an anti-reflux medication. Overall, this case report emphasizes the importance of recognizing other atypical presentations in relation to MI. Additionally, this highlights the importance of the clinician's role in assessing the heart and coronary arteries when evaluating CT scans.

Atypical Presentations of Myocardial Infarction: A Systematic Review of Case Reports

There is a rising incidence of coronary artery diseases and myocardial infarction (MI). Mortality associated with acute MI (AMI) is directly linked to the time to receive treatment and missed diagnoses. Although health professionals are aware of typical AMI presentation, atypical MI is difficult to diagnose, which on the other hand, is likely to have an impact on morbidity and mortality. Therefore, it is prudent to know such atypical presentations, especially for emergency and primary care physicians. We aimed to systematically evaluate the clinical presentations of atypical MI and analyze them to characterize the common clinical presentations of atypical MI. We researched the PubMed database, did citation tracking, and performed Google Scholar advanced search to find the cases reported on the atypical presentation of MI published from January 2000 to September 2022. Articles of all languages were included; Google Translate was used to translate articles published in languages other than English. A total of 496 (56 PubMed articles, 340 citations from included PubMed articles, and 100 articles from Google Scholar advanced search) were screened; 52 case reports were evaluated, and their data were analyzed. Atypical presentations of myocardial infarction are vast; patients may have chest pain without typical characteristics of angina pain or may not have chest pain. No typical characterization could be done. Most patients were in their fifth decade or above of their life and commonly presented with pain and discomfort in the abdomen, head, and neck regions. Prodromal symptoms were consistent findings, and many patients had two to three comorbidities out of four common comorbidities, i.e., diabetes, hypertension, dyslipidemia, and substance abuse. A patient who is 50 years old or more, having comorbidities such as diabetes, hypertension, dyslipidemia, history of tobacco or marijuana usage, presenting with prodromal symptoms like shortness of breath, dizziness, fatigue, syncope, gastrointestinal discomfort or head/neck pain should be suspected for atypical MI.

Potentially Inappropriate Medication Use in Older Adults in the Preoperative Period: A Retrospective Study of a Noncardiac Surgery Cohort

Background

Few studies have evaluated the prevalence of potentially inappropriate medications (PIMs) and its association with postoperative outcomes in a geriatric population in the preoperative setting.

Objectives

The purpose of this study was to evaluate the prevalence of PIMs in an older elective surgery population and to explore associations between PIMs and postoperative length of stay (LOS) and emergency department (ED) visits in the 90 days post hospital discharge, depending on frailty status.

Methodology

We performed a retrospective cohort study of older adults awaiting major elective noncardiac surgery and undergoing an evaluation in the preoperative clinic at a tertiary academic center between 2017 and 2018. We identified PIMs using MedSafer, a software tool built to improve the safety of prescribing. Frailty status was assessed using the 7-point Clinical Frailty Scale. We estimated the association between PIMs and postoperative LOS and ED visits in the 90 days post hospital discharge.

Results

The MedSafer software generated 394 recommendations on PIMs in 1619 medications for 252 patients. In total, 197 (78%) patients had at least one PIM. The cohort included 138 (51%) robust, 87 (32.2%) vulnerable and 45 (16.7%) frail patients. The association between PIMs and LOS was not significant for the robust and frail subgroups. For the vulnerable patients, every additional PIM increased LOS by 20% (incidence rate ratio 1.20; 95% confidence interval 0.90–1.44; p = 0.089) without reaching statistical significance. No association was found between PIMs and ED visits.

Conclusion

PIMs identified by the MedSafer software were prevalent. Preoperative evaluation represents an opportunity to plan deprescribing of PIMs.

Electronic supplementary material

The online version of this article (10.1007/s40801-020-00190-y) contains supplementary material, which is available to authorized users.

Atypical Presentation of Bacteremia in Older Patients Is a Risk Factor for Death

BACKGROUND

The absence of fever in bacteremia in patients who are older is known to delay diagnosis. Our objective was to determine whether atypical presentation was associated to mortality as a result of bacteremia in this patient cohort as well as possible factors associated with this atypical presentation.

METHODS

We conducted an observational prospective study in 2 French university hospitals in 2016-2017 including patients ages ≥75 years with bacteremia. Atypical presentation was defined as the absence of a temperature ≥38.3°C or <36°C, chills, or hypotension. Mortality and dependence for activities of daily living (ADL) were recorded at 1 week (D7) and 3 months (D90).

RESULTS

Among the 151 patients (mean age 85.4±5.8 years) enrolled, atypical presentation prevalence was 21.2%. D7 and D90 mortality rates were 7.9% and 40.0%, respectively. Atypical presentation was independently associated with D7 (odds ratio (OR) 4.46, 95% confidence interval (CI) 1.04-19.24) and D90 mortality (OR 3.76, 95% CI 1.30-10.92) after controlling for other prognostic factors. Patients with diabetes and those infected with Staphylococcus aureus were more likely to have atypical signs of infection. ADL score decreased from 3.6±2.0 before bacteremia to 2.8±2.1 at D90 (P <0.001).

CONCLUSION

Patients who are older with bacteremia have poor vital and functional prognoses in the short and long terms. The absence of typical signs of infection is associated with mortality. Blood culture should be considered for patients who are older, especially with diabetes with acute unexplained clinical manifestations.