Medicine II Althea Ninotschka Agaloos

Body Interact Case 2021-0088

1. Final Diagnosis: ST Elevation Myocardial Infarction

An ST-elevation myocardial infarction occurs from occlusion of one or more of the
coronary arteries that supply the heart with blood. The cause of this abrupt disruption of
blood flow is usually plaque rupture, erosion, fissuring or dissection of coronary arteries
that results in an obstructing thrombus (Akbar et al., 2023). The major risk factors for
STEMI are dyslipidemia, diabetes mellitus, hypertension, and smoking, all of which the
patient has. The patient’s chest pain and tightness radiating to both upper limbs,
dyspnea, diaphoresis, and elevated Troponin I and Myoglobin, suggest an acute
myocardial infarction. Upon focused cardiac physical examination, the patient has no
chest tenderness upon palpation, diminished heart sounds, strong and rhythmic pulses,
and normal capillary refill time. There is also a total occlusion of the middle left anterior
descending artery as seen in coronary angiography and this is consistent with the ECG
finding of an acute injury current in V1 through V4. TTE showed severe left ventricular
dilation and severe left ventricular systolic dysfunction with septal and apical
hypokinesia. These imaging findings are all consistent with STEMI.

2. Differential Diagnoses:
a. Aortic Dissection
Aortic dissection occurs when there is a tear in the intimal layer, followed by the
formation and propagation of a subintimal hematoma, leading to the
development of a false lumen or double-barreled aorta (Mancini, 2022). This
reduces the blood flow to the arteries originating from the aorta. The severe and
sudden onset of chest pain increases the suspicion of an aortic dissection. The
enlargement of mediastinum, cardiomegaly, aortic calcification, and pleural
effusion may raise suspicion for aortic disease, but chest radiographs are not
sensitive in diagnosing acute aortic syndromes (Evangelista et al., 2005). The
patient is at an increased risk of having this because of his hypertension,
hyperlipidemia, coronary artery disease, and tobacco use which are all known
risk factors for aortic dissection (Nathan et al., 2012). The patient also described
his chest pain as a feeling of tightness which also radiates to the upper arms,
which is different from the pain in aortic dissection which is usually characterized
as sharp and tearing pain. The patient also has strong and rhythmic pulses on all
four extremities, which is contrary to the finding of unequal pulses in aortic
dissection (Singh et al., 2023).
b. Congestive Heart Failure
Congestive heart failure is characterized by inefficient myocardial performance,
resulting in compromised blood supply to the body, resulting from any disorder
that impairs ventricular filling or ejection of blood to the systemic circulation
(Malik et al., 2023). The presence of chest pain and tightness, shortness of
breath, hypertension, fatigue may increase the suspicion for heart failure. The
Medicine II Althea Ninotschka Agaloos
Body Interact Case 2021-0088

crackles on the left lung upon auscultation, dull percussion sounds on the
middle to lower lung fields, the blunting of the left costophrenic angle on chest
radiograph, and the decreased urine output suggest pleural effusion and fluid
retention which may be associated with heart failure. Increased BNP may also
point towards heart failure as ventricular myocytes are stimulated to secrete
both ANP and BNP in response to increased strain caused by high ventricular
filling pressures (Colucci & Chen, 2024). The patient’s troponin I is also
increased, which may indicate acute decompensated HF or acute coronary
syndrome. The patient’s elevated liver enzymes may also suggest hepatic
congestion which is common in heart failure.

c. Pericarditis
Acute pericarditis is an inflammation of the pericardium characterized by
pericarditic chest pain, pericardial friction rub, and new widespread ST-elevation
or PR depression, or pericardial effusion (Spangler, 2020). The presence of chest
pain and ECG changes in the patient, along with cardiomegaly on chest
radiograph and the increase in cardiac troponin I may increase the suspicion for
pericarditis. However, there are no signs of inflammation both during the clinical
assessment and lab tests, so a different etiology may be considered.

d. Pulmonary Embolism
Pulmonary embolism occurs when a thrombus becomes lodged in an artery in
the lung and lodges at the bifurcation of the main pulmonary artery or the lobar
branches, causing hemodynamic compromise (Ouellette, 2020). The patient
presented with an abrupt onset of chest pain with a feeling of tightness as well
as difficulty breathing, which could point to a possible pulmonary embolism
given that the patient also has risk factors for pulmonary embolism including
hyperlipidemia and smoking. The presence of crackles upon auscultation and
diaphoresis are also some of the common physical findings in pulmonary
embolism. However, the absence of hypoxia, cyanosis, cough, tachypnea,
history of hypercoagulable state, and other respiratory complaints may point
more towards a different etiology.
Medicine II Althea Ninotschka Agaloos
Body Interact Case 2021-0088

References:
Akbar, H., Foth, C., Kahloon, R. A., & Mountfort, S. (2023, July 31). Acute ST-Elevation
myocardial infarction. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK532281/

Colucci, W., & Chen, H. (2024). Natriuretic peptide measurement in heart failure. UpToDate.
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Evangelista, A., Mukherjee, D., Mehta, R. H., O’Gara, P. T., Fattori, R., Cooper, J. V., Smith, D.
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https://doi.org/10.1161/01.cir.0000156444.26393.80

Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2023, November 5). Congestive heart failure.
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0(CHF)%20is,blood%20to%20the%20systemic%20circulation.

Mancini, M. (2022). Aortic Dissection: practice essentials, background, anatomy.

https://emedicine.medscape.com/article/2062452-overview

Nathan, D. P., Boonn, W. W., Lai, E., Wang, G. J., Desai, N. D., Woo, E. Y., Fairman, R. M., &
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Ouellette, D. R. (2020). Pulmonary Embolism (PE): practice essentials, background, anatomy.

https://emedicine.medscape.com/article/300901-overview

Singh, A., Museedi, A. S., & Grossman, S. A. (2023, July 10). Acute coronary syndrome.
StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK459157/

Spangler, S., MD. (2020). Acute Pericarditis: practice Essentials, background, anatomy.
https://emedicine.medscape.com/article/156951-overview