‘Will you come down to the hospital to see yet another football player? He doesn’t look too good. Probably has broken ribs and pneumothorax.’.
‘Typical Saturday afternoon’, I thought as I went to see Robert S, aged 22. Robert was holding a painful precordium and looking pale and sweaty. ‘Did you get a heavy knock?’ ‘No, not really.’ His chest was normal on clinical examination. ‘If he was older I’d think it was myocardial infarction’, I thought just before he moaned loudly and then collapsed.
Resuscitation, despite optimal facilities, was unsuccessful. Autopsy showed acute myocardial infarction (AMI).
Lila J, aged 62, was the local Methodist minister’s wife, a truly beautiful person who attended me for hypertension. One evening I was called to her home because I was told: ‘Mum is complaining of a funny constricting feeling in her throat and is having trouble breathing. We’ve had fish for tea and we think she must be allergic to it’.
I hurried to treat the acute allergic problem, only to find a very pale and anxious-looking lady who said, ‘My throat is tight and closing up’. As I nervously felt a slow and irregular pulse, she had a cardiac arrest.
To the horror of the onlooking loved ones, I commenced cardiopulmonary resuscitation and asked one of the relatives to bring in my portable defibrillator. This was successful initially but she died some time later in hospital.
Alan P, aged 49, is a mountain of a man who uses jackhammers each day as he drills through concrete. He presented one afternoon looking quite well but claiming, ‘This work is catching up with me—I’ve had terribly aching arms all day’. Further questioning revealed that he had the pain in both forearms for five hours and then reluctantly came in when he felt ‘lightheaded and peculiar’. I could find nothing abnormal on examination but intuitively took blood for cardiac enzymes and performed an ECG—another AMI.
Mary B, a 41-year-old housewife, presented with the sudden onset of severe pain in the interscapular area of her back. However, I could find no abnormality on examination of her thoracic spine. My provisional diagnosis included a pathological fracture in an osteoporotic vertebra, but a routine ECG provided the answer to the unusual presentation—AMI and not a twinge of discomfort in the anterior chest.
I was called to see Sarah C, a 72-year-old diabetic, at 3 am because of the sudden onset of dyspnoea. ‘An easy one’, I thought as I sped to the farmhouse. ‘Morphine, frusemide and oxygen will fix her acute pulmonary oedema in no time. Love treating them.’ Well, that treatment did not make any impression on her distress (anxiety, sweating, dyspnoea). Unfortunately, she died in hospital from the complications of her AMI. Never a complaint of chest pain—a truly silent AMI that precipitated acute cardiac failure.
A first-aid person rang me one afternoon to say that 78-year-old Minnie P had been run over by a car in the main street of the town. ‘She’s in bad shape—multiple fractures, ribs and left humerus at least.’.
My first sighting in the casualty area was a ‘shocked’ elderly lady with abrasions who was moaning with pain. She pointed to her sternum, precordium and left arm. There was no clinical evidence of fractures. I quickly organised an ECG, which confirmed AMI. Minnie died two hours later. The attending policeman said, ‘The driver had been let off the hook. He was emphatic that she suddenly fell onto the road and then under the car as she was crossing it in front of him’.
Phyllis M, aged 62, a close relative of the author, requested another opinion about severe epigastric pains and ‘indigestion’ diagnosed as a peptic ulcer but unrelieved by antacids and H2 antagonists. It was a real brain teaser, but her obvious pallor and discomfort prompted an ECG, which confirmed a recent AMI.
DISCUSSION AND LESSONS LEARNED
Acute coronary syndromes and coronary artery disease in general are common and can be easily missed, especially if presentation is atypical, as highlighted in these case histories.
It is vital to make an early diagnosis of these cases and transfer patients to a specialist coronary care unit. Statistics show that most deaths occur in the first 1 to 2 hours, and that chances of survival are improved significantly in these special units and with the attendance of special intensive-care ambulances. Ideally we prefer to have these patients admitted to a coronary intervention unit within 60–90 minutes of the onset of pain.
It appears to be easier to overlook an acute coronary syndrome (AMI) in the context of a busy surgery, especially as so many causes of chest pain are not, as expected, due to coronary insufficiency.
The advent of more sensitive cardiac enzyme markers such as the troponins has improved our diagnostic rate.
Age appears to be no barrier to diagnosis. Reports of death from unsuspected AMI in people in their twenties and thirties are commonplace.
Smoking, hyperlipidaemia, diabetes mellitus and hypertension are obviously common associations in these patients. I refer to these as ‘the four horsemen of the apocalypse’.