ST elevation myocardial infarction differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{ST elevation myocardial infarction}}
[[Image:Home_logo1.png|right|250px|link=http://www.wikidoc.org/index.php/ST_elevation_myocardial_infarction]]
{{CMG}}; {{AE}} {{CZ}}
{{CMG}}; {{AE}} {{CZ}}


==Overview==
==Overview==
ST segment myocardial infarction can be broadly categorized, from a patient perspective, as chest pain. In addition, ST segment myocardial infarction diagnosis can be influence by both, the absence and presence of myonecrosis. A thorough differential diagnosis is necessary to eliminate extraneous causation within a patient diagnosis.
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:<ref name="pmid30913893">{{cite journal| author=Tamis-Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM et al.| title=Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. | journal=Circulation | year= 2019 | volume=  | issue=  | pages= CIR0000000000000670 | pmid=30913893 | doi=10.1161/CIR.0000000000000670 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30913893  }} </ref><ref name="pmid14645641">{{cite journal |author=Wang K, Asinger RW, Marriott HJ |title=ST-segment elevation in conditions other than acute myocardial infarction |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2128–35 |year=2003 |month=November |pmid=14645641 |doi=10.1056/NEJMra022580 |url=}}</ref><ref name="pmid15014192">{{cite journal |author=Ako J, Honda Y, Fitzgerald PJ |title=Conditions associated with ST-segment elevation |journal=N. Engl. J. Med. |volume=350 |issue=11 |pages=1152–5; author reply 1152–5 |year=2004 |month=March |pmid=15014192 |doi=10.1056/NEJM200403113501118 |url=}}</ref>
 
====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]]
* [[Cardioversion|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 [[The electrocardiogram|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 complex|QRS]]. Stated differently, if the [[QRS complex|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 complex|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 hyper-[[adrenergic]] 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-blocker]]s, and [[myocardial contusion]] would not be treated with an [[antithrombin]]. These conditions include the following:
 
====By Organ System====
 
{| style="width:75%; height:100px" border="1"
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" | '''Cardiovascular'''
| style="width:75%" bgcolor="Beige" ; border="1" | [[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
 
|-
|- bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
| bgcolor="Beige" | [[Carbon monoxide poisoning]]
|-
|- bgcolor="LightSteelBlue"
| '''Dermatologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
| bgcolor="Beige" | [[Oral contraceptive pills]], particularly among women who smoke
 
[[Anabolic steroids]]
|-
|- bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
| bgcolor="Beige" | A recent [[upper respiratory tract infection]]s has been associated with a 4.9 fold rise in the risk of [[trigger of MI|MI]]
|-
|- bgcolor="LightSteelBlue"
| '''Endocrine'''
| bgcolor="Beige" | [[Thyrotoxicosis]]
|-
|- bgcolor="LightSteelBlue"
| '''Environmental'''
| bgcolor="Beige" | 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]].
|-
|- bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
| bgcolor="Beige" | A heavy meal has been associated with a 4 fold rise in the risk of [[trigger of MI|MI]], and it is not clear if this is mediated by hyper-[[adrenergic]] tone<ref name="pmid15609883">{{cite journal |author=Lipovetzky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS |title=Heavy meals as a trigger for a first event of the acute coronary syndrome: a case-crossover study |journal=Isr. Med. Assoc. J. |volume=6 |issue=12 |pages=728–31 |year=2004 |month=December |pmid=15609883 |doi= |url=}}</ref>;
|-
|- bgcolor="LightSteelBlue"
| '''Genetic'''
| bgcolor="Beige" | [[Familial hypercholesterolemia]]
|-
|- bgcolor="LightSteelBlue"
| '''Hematologic'''
| bgcolor="Beige" | [[Disseminated intravascular coagulation]] ([[DIC]])
 
[[Hypercoagulable states]]
 
[[Polycythemia vera]]
 
[[Thrombocytosis]]
|-
|- bgcolor="LightSteelBlue"
| '''Iatrogenic'''
| bgcolor="Beige" | [[Epinephrine]] overdose
 
Sudden withdrawal of [[Beta blockers]] or [[nitrates]]
|-
|- bgcolor="LightSteelBlue"
| '''Infectious Disease'''
| bgcolor="Beige" | A recent [[upper respiratory tract infection]]s has been associated with a 4.9 fold rise in the risk of [[trigger of MI|MI]]
 
[[Infectious endocarditis]] may STEMI as a result of [[embolization]]
|-
|- bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Neurologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
| bgcolor="Beige" | A heavy meal has been associated with a 4 fold rise in the risk of [[trigger of MI|MI]] and it is not clear if this is mediated by hyper-[[adrenergic]] tone<ref name="pmid15609883">{{cite journal |author=Lipovetzky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS |title=Heavy meals as a trigger for a first event of the acute coronary syndrome: a case-crossover study |journal=Isr. Med. Assoc. J. |volume=6 |issue=12 |pages=728–31 |year=2004 |month=December |pmid=15609883 |doi= |url=}}</ref>;
 
[[Amyloidosis]]
 
[[Fabry disease]]
 
[[Homocystinuria]]
 
[[Mucopolysaccharidoses]] or [[Hurler disease]]
 
[[Pseudoxanthoma elasticum]]
 
[[Thiamine deficiency]] has been associated with [[ST elevation]] and [[myonecrosis]] <ref name="pmid16020883">{{cite journal |author=Kawano H, Koide Y, Toda G, Yano K |title=ST-segment elevation of electrocardiogram in a patient with Shoshin beriberi |journal=Intern. Med. |volume=44 |issue=6 |pages=578–85 |year=2005 |month=June |pmid=16020883 |doi= |url=http://joi.jlc.jst.go.jp/JST.JSTAGE/internalmedicine/44.578?from=PubMed}}</ref><ref>Hundley JM, Ashburn LL, Sebrell WH. The electrocardiogram in chronic thiamine deficiency in rats. Am J Physiol 144: 404–414, 1954. </ref><ref name="pmid7197132">{{cite journal |author=Read DH, Harrington DD |title=Experimentally induced thiamine deficiency in beagle dogs: clinical observations |journal=Am. J. Vet. Res. |volume=42 |issue=6 |pages=984–91 |year=1981 |month=June |pmid=7197132 |doi= |url=}}</ref>
|-
|- bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
| bgcolor="Beige" | Spontaneous [[coronary]] [[dissection]] in the setting of [[pregnancy]]
|-
|- bgcolor="LightSteelBlue"
| '''Oncologic'''
| bgcolor="Beige" | [[Radiation therapy]] can accelerate [[atherosclerosis]] particularly in the distribution of the [[left anterior descending artery]];
|-
|- bgcolor="LightSteelBlue"
| '''Opthalmologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
| bgcolor="Beige" | [[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]].
|-
|- bgcolor="LightSteelBlue"
| '''Psychiatric'''
| bgcolor="Beige" | 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 hyper-[[adrenergic]] 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 hyper-[[adrenergic]] stimulation emanating from the [[central nervous system]].
|-
|- bgcolor="LightSteelBlue"
| '''Pulmonary'''
| bgcolor="Beige" | A recent [[upper respiratory tract infection]]s has been associated with a 4.9 fold rise in the risk of [[trigger of MI|MI]]
|-
|- bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
| bgcolor="Beige" | [[Homocystinuria]]
|-
|- bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
| bgcolor="Beige" | Takayasus
|-
|- bgcolor="LightSteelBlue"
| '''Sexual'''
| bgcolor="Beige" | Sexual activity has been identified as a [[trigger of MI]]
|-
|- bgcolor="LightSteelBlue"
| '''Trauma'''
| bgcolor="Beige" | Both penetrating and non-penetrating [[trauma]] to the [[heart]] or [[myocardial contusion]], [[commotio cordis]] can be associated with [[ST elevation]] and [[myonecrosis]].
|-
|- bgcolor="LightSteelBlue"
| '''Urologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Miscellaneous'''
| bgcolor="Beige" | [[Hypotension]] particularly if it is prolonged
|-
|}


==Complete Differential Diagnosis of Chest Pain==
==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===
* [[Aortic dissection]]
* [[Esophageal rupture]]
* [[Myocardial infarction]]
* [[Pulmonary embolism]]
* [[Tension pneumothorax]]
The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is:<ref name="pmid8809520">{{cite journal |author=Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K |title=The diagnoses of patients admitted with acute chest pain but without myocardial infarction |journal=[[European Heart Journal]] |volume=17 |issue=7 |pages=1028–34 |year=1996 |month=July |pmid=8809520 |doi= |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8809520 |accessdate=2012-05-02}}</ref>
*Gastroesophageal disease
*[[Ischemic heart disease]] (angina, not myocardial infarction)
*[[Chest wall]] syndromes
===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====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! 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)
  |[[Diaphoresis|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 (medical)|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 (medicine)|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====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! 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.
|-
  |'''[[Pneumothorax|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 (medical)|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 (medicine)|Acute]], [[subacute]], [[Chronic (medical)|chronic]]
  |Variable
  |Pressure like
  |Substernal
  |Not specific
  |Not specific
  |Not specific
  |[[Dyspnea]], [[symptoms]] of [[right heart failure]] ([[edema]]
|-
|}
====GASTROINTESTINAL====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! 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 (medicine)|Acute]]
  |Minutes to hours
  |Burning, pressure
  |Retrosternal
  |Not specific
  |Relieved by sublingual [[nitroglycerine]]
  |Not specific
  |Not specific (closely mimic angina)
|-
  |'''[[Gallstone disease| Cholelithiasis]]'''
  |[[Acute (medicine)|Acute]], [[subacute]]
  |Minutes to hours
  |Burning, [[Colicky flank pain|colicky]]
  |Right upper [[abdomen]], substernal, [[epigastric]]
  |Increases post meal, fatty food, 1-2 hours post meal
  |[[Analgesics]]
  |Not specific
  |Not specific
|-
|}
====MISCELLANEOUS====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! Condition
  ! Onset
  ! Duration
  ! Type of pain
  ! Location
  ! Exacerbating factors
  ! Alleviating factors
  ! Radiation
  ! Associated features
|-
  |'''[[Muscular pain|Musculo-skeletal Pain]]'''
  |[[Acute (medicine)|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 (medicine)|Acute]], [[subacute]], [[Chronic (medical)|chronic]]
  |Variable
  |Variable
  |Variable
  |Variable
  |Not specific
  |Not specific
  |History of [[depression]], [[panic attacks]], agrophobia
|-
|}
====By Organ System====
====By Organ System====
{|style="width:60%; height:100px" border="1"
{| style="width:60%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | • [[Aortic Dissection|Acute Aortic Dissection]] • [[Acute Coronary Syndrome]] • ([[unstable angina]]) • ([[non ST elevation MI]]) • ([[ST elevation MI]]) • [[Aortic Aneurysm]] • [[Aortic Stenosis]] • [[Arryhthmias]] • [[Bland-White-Garland Syndrome]] • [[Chronic Stable Angina]] • [[Cor pulmonale]] • [[Coronary Heart Disease]] • [[Dressler's syndrome | Dressler's syndrome (postpericardiotomy)]] • [[Cardiomyopathy|Hypertrophic Cardiomyopathy]] • [[Mitral valve prolapse]] • [[STEMI|Myocardial infarction]] • [[Myocarditis]] • [[tamponade|Pericardial tamponade]] • [[Pericarditis]] • [[Takotsubos cardiomyopathy]] • [[Stress cardiomyopathy]]
| style="width:75%" bgcolor="Beige" ; border="1" | • [[Aortic Dissection|Acute Aortic Dissection]] • [[Acute Coronary Syndrome]] • ([[unstable angina]]) • ([[non ST elevation MI]]) • ([[ST elevation MI]]) • [[Aortic Aneurysm]] • [[Aortic Stenosis]] • [[Arryhthmias]] • [[Bland-White-Garland Syndrome]] • [[Chronic Stable Angina]] • [[Cor pulmonale]] • [[Coronary Heart Disease]] • [[Dressler's syndrome | Dressler's syndrome (postpericardiotomy)]] • [[Cardiomyopathy|Hypertrophic Cardiomyopathy]] • [[Mitral valve prolapse]] • [[STEMI|Myocardial infarction]] • [[Myocarditis]] • [[tamponade|Pericardial tamponade]] • [[Pericarditis]] • [[Takotsubos cardiomyopathy]] • [[Stress cardiomyopathy]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
| '''Chemical / poisoning'''
|bgcolor="Beige"| No underlying causes  
| bgcolor="Beige" | No underlying causes  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Dermatologic'''
| '''Dermatologic'''
|bgcolor="Beige"| [[Herpes zoster]]
| bgcolor="Beige" | [[Herpes zoster]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
| '''Drug Side Effect'''
|bgcolor="Beige"| Drugs to treat [[migraine headache]]
| bgcolor="Beige" | Drugs to treat [[migraine headache]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
| '''Ear Nose Throat'''
|bgcolor="Beige"| • [[Retropharyngeal abscess]]  
| bgcolor="Beige" | • [[Retropharyngeal abscess]]  
|-  
|-  
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Endocrine'''
| '''Endocrine'''
|bgcolor="Beige"| • [[Acromegaly]]   
| bgcolor="Beige" | • [[Acromegaly]]   
|-  
|-  
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Environmental'''
| '''Environmental'''
|bgcolor="Beige"| No underlying causes  
| bgcolor="Beige" | No underlying causes  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
| '''Gastroenterologic'''
|bgcolor="Beige"| • [[Achalasia]] • [[Abdominal distension]] • [[Barret’s esophagus]] • [[Carcinoma]] • [[Cholecystitis]] • [[Cholelithiasis]] • [[Diverticulitis]] • [[Duodenitis]] • [[Esophageal rupture]] • [[Esophageal spasm]] • [[Esophagitis]] • [[Foreign body]] • [[Gastritis]] • [[Gastroesophageal reflux]] ([[GERD]]) • [[Hiatus Hernia]] • [[Impacted stone]] • [[Liver abscess]] • [[Mallory-Weiss Syndrome]] • [[Neoplasm]] • [[nutcracker's esophagus|Nutcracker's esophagus]] • [[Pancreatitis]] • [[Peptic ulcer disease]] • [[Perforated ulcer]] • [[Plummer-Vinson Syndrome]] • [[Pneumoperitoneum]] • [[Splenomegaly|Splenic enlargement]] • [[Splenic infarction]] • Subdiaphragmatic abcsess • [[Subphrenic abscess]] • [[Whipple's Disease]]  
| bgcolor="Beige" | • [[Achalasia]] • [[Abdominal distension]] • [[Barret’s esophagus]] • [[Carcinoma]] • [[Cholecystitis]] • [[Cholelithiasis]] • [[Diverticulitis]] • [[Duodenitis]] • [[Esophageal rupture]] • [[Esophageal spasm]] • [[Esophagitis]] • [[Foreign body]] • [[Gastritis]] • [[Gastroesophageal reflux]] ([[GERD]]) • [[Hiatus Hernia]] • [[Impacted stone]] • [[Liver abscess]] • [[Mallory-Weiss Syndrome]] • [[Neoplasm]] • [[nutcracker's esophagus|Nutcracker's esophagus]] • [[Pancreatitis]] • [[Peptic ulcer disease]] • [[Perforated ulcer]] • [[Plummer-Vinson Syndrome]] • [[Pneumoperitoneum]] • [[Splenomegaly|Splenic enlargement]] • [[Splenic infarction]] • Subdiaphragmatic abcsess • [[Subphrenic abscess]] • [[Whipple's Disease]]  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Genetic'''
| '''Genetic'''
|bgcolor="Beige"| No underlying causes  
| bgcolor="Beige" | No underlying causes  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Hematologic'''
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes   
| bgcolor="Beige" | No underlying causes   
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Iatrogenic'''
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes  
| bgcolor="Beige" | No underlying causes  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Infectious Disease'''
| '''Infectious Disease'''
|bgcolor="Beige"| • [[Bornholm disease]] • [[Hepatitis]] • [[HIV|HIV infection]] • [[Herpes Zoster]]  
| bgcolor="Beige" | • [[Bornholm disease]] • [[Hepatitis]] • [[HIV|HIV infection]] • [[Herpes Zoster]]  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| • [[Bechterew's Disease]] • [[Bone tumor]] • Chest wall injuries • Chest wall pain syndrome • [[Costochondritis]] • Chosto condral tendinitis • Chosto sternal tendinitis • [[Tietze's syndrome]] • CS/TS osteochondrosis • [[Fibromyalgia]] • [[Fractured rib]] • [[Intercostal muscle spasm]] • Interstitial fibrosis • [[Intercostal neuralgia]] • [[Muscle strain or spasm]] • Myofascial pain • [[Myostitis]] • [[Neuritis]] • [[Radiculitis]] • [[Periostitis]] • [[Precordial catch syndrome]] • [[bursitis|Shoulder bursitis]] • [[tendinitis|Shoulder tendinitis]] • [[tumor|Soft tissue sarcoma or tumor]] • Sternoclavicular arthritis • Strain of pectoralis muscle • [[Thoracic Outlet Syndrome]] • [[Trauma]] • Vertebrogenic thoracic pain
| bgcolor="Beige" | • [[Bechterew's Disease]] • [[Bone tumor]] • Chest wall injuries • Chest wall pain syndrome • [[Costochondritis]] • Chosto condral tendinitis • Chosto sternal tendinitis • [[Tietze's syndrome]] • CS/TS osteochondrosis • [[Fibromyalgia]] • [[Fractured rib]] • [[Intercostal muscle spasm]] • Interstitial fibrosis • [[Intercostal neuralgia]] • [[Muscle strain or spasm]] • Myofascial pain • [[Myostitis]] • [[Neuritis]] • [[Radiculitis]] • [[Periostitis]] • [[Precordial catch syndrome]] • [[bursitis|Shoulder bursitis]] • [[tendinitis|Shoulder tendinitis]] • [[tumor|Soft tissue sarcoma or tumor]] • Sternoclavicular arthritis • Strain of pectoralis muscle • [[Thoracic Outlet Syndrome]] • [[Trauma]] • Vertebrogenic thoracic pain
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Neurologic'''
| '''Neurologic'''
|bgcolor="Beige"| • [[Tabes dorsalis]]  
| bgcolor="Beige" | • [[Tabes dorsalis]]  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
| '''Nutritional / Metabolic'''
|bgcolor="Beige"| No underlying causes   
| bgcolor="Beige" | No underlying causes   
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Oncologic'''
| '''Oncologic'''
|bgcolor="Beige"| • [[Liver cancer]] • [[Mesothelioma]] • [[Metastatic tumor]] • [[Neurofibroma]] • [[Pheochromocytoma]]  
| bgcolor="Beige" | • [[Liver cancer]] • [[Mesothelioma]] • [[Metastatic tumor]] • [[Neurofibroma]] • [[Pheochromocytoma]]  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Opthalmologic'''
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes  
| bgcolor="Beige" | No underlying causes  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
| '''Overdose / Toxicity'''
|bgcolor="Beige"| No underlying causes   
| bgcolor="Beige" | No underlying causes   
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Psychiatric'''
| '''Psychiatric'''
|bgcolor="Beige"| • [[Anxiety|Anxiety disorders]] • [[Affective disorders]] (e.g., [[depression]]) • [[Da costa's syndrome]] • Thought disorders (e.g., [[delusions|fixed delusions]]) • [[Hyperventilation syndrome]] • [[Hypochondria]] • [[Factitious disorders]] (e.g. [[Münchausen syndrome]] • [[Fabricated or induced illness]] • Hospital addiction syndrome) • [[Panic attack]] • [[Somatoform disorder]]s •  [[Somatization disorder]]  
| bgcolor="Beige" | • [[Anxiety|Anxiety disorders]] • [[Affective disorders]] (e.g., [[depression]]) • [[Da costa's syndrome]] • Thought disorders (e.g., [[delusions|fixed delusions]]) • [[Hyperventilation syndrome]] • [[Hypochondria]] • [[Factitious disorders]] (e.g. [[Münchausen syndrome]] • [[Fabricated or induced illness]] • Hospital addiction syndrome) • [[Panic attack]] • [[Somatoform disorder]]s •  [[Somatization disorder]]  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Pulmonary'''
| '''Pulmonary'''
|bgcolor="Beige"| • [[Asthma]] • [[Bronchial carcinoma]] • [[Bronchiectasis]] • [[Bronchogenic carcinoma]] • [[Carcinomatous]] • [[Pleural Effusion]] • [[Chronic Obstructive Pulmonary Disease]] ([[COPD]]) • [[Empyema]] • [[Hemothorax]] • [[Lung Abscess]] • [[Lung Cancer]] • [[Lymphoma]] • [[Mediastinitis]] • [[Pleuritis]] • [[Pleurodynia]] • [[Pneumomediastinum]] • [[Pneumonia]] • [[Pneumothorax]] • [[Pulmonary Embolism]] • [[Pulmonary Infarction]] • [[pneumothorax|Tension pneumothorax]] • [[Thymoma]] • Tracheoesophageal abscess • [[Tuberculosis]]   
| bgcolor="Beige" | • [[Asthma]] • [[Bronchial carcinoma]] • [[Bronchiectasis]] • [[Bronchogenic carcinoma]] • [[Carcinomatous]] • [[Pleural Effusion]] • [[Chronic Obstructive Pulmonary Disease]] ([[COPD]]) • [[Empyema]] • [[Hemothorax]] • [[Lung Abscess]] • [[Lung Cancer]] • [[Lymphoma]] • [[Mediastinitis]] • [[Pleuritis]] • [[Pleurodynia]] • [[Pneumomediastinum]] • [[Pneumonia]] • [[Pneumothorax]] • [[Pulmonary Embolism]] • [[Pulmonary Infarction]] • [[pneumothorax|Tension pneumothorax]] • [[Thymoma]] • Tracheoesophageal abscess • [[Tuberculosis]]   
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
| '''Renal / Electrolyte'''
|bgcolor="Beige"| No underlying causes  
| bgcolor="Beige" | No underlying causes  
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"| No underlying causes   
| bgcolor="Beige" | No underlying causes   
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Trauma'''
| '''Trauma'''
|bgcolor="Beige"| No underlying causes   
| bgcolor="Beige" | No underlying causes   
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Miscellaneous'''
| '''Miscellaneous'''
|bgcolor="Beige"| • Collagen vascular disease with pleuritis • [[Conn's Syndrome]] • Degenerative changes of cervical spine • [[Familial Mediterranean Fever]] • [[Peritonitis]] • [[Pott's Disease]] • Xyphodenia  
| bgcolor="Beige" | • Collagen vascular disease with pleuritis • [[Conn's Syndrome]] • Degenerative changes of cervical spine • [[Familial Mediterranean Fever]] • [[Peritonitis]] • [[Pott's Disease]] • Xyphodenia  
|-
|-
|}
|}
Line 171: Line 567:
*[[SAPHO syndrome]]
*[[SAPHO syndrome]]
*[[Shingles]]
*[[Shingles]]
*[[Sickle cell crisis]] (thrombotic)
*[[Sickle cell crisis]] ([[thrombotic]])
*[[Sickle cell disease]]
*[[Sickle cell disease]]
*[[Spinal cord injury|Acute spinal cord injury]]
*[[Spinal cord injury|Acute spinal cord injury]]
Line 188: Line 584:
*[[Wegener granulomatosis]]
*[[Wegener granulomatosis]]
*[[Zolmitriptan]]
*[[Zolmitriptan]]
==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:<ref name="pmid14645641">{{cite journal |author=Wang K, Asinger RW, Marriott HJ |title=ST-segment elevation in conditions other than acute myocardial infarction |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2128–35 |year=2003 |month=November |pmid=14645641 |doi=10.1056/NEJMra022580 |url=}}</ref><ref name="pmid15014192">{{cite journal |author=Ako J, Honda Y, Fitzgerald PJ |title=Conditions associated with ST-segment elevation |journal=N. Engl. J. Med. |volume=350 |issue=11 |pages=1152–5; author reply 1152–5 |year=2004 |month=March |pmid=15014192 |doi=10.1056/NEJM200403113501118 |url=}}</ref>
====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]]
* [[Cardioversion|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-blocker]]s, and [[myocardial contusion]] would not be treated with an [[antithrombin]]. These conditions include the following:
====By Organ System====
{|style="width:75%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[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
|-
|-bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
|bgcolor="Beige"| [[Carbon monoxide poisoning]]
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| [[Oral contraceptive pills]], particularly among women who smoke
[[Anabolic steroids]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| A recent [[upper respiratory tract infection]]s has been associated with a 4.9 fold rise in the risk of [[trigger of MI|MI]]
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| [[Thyrotoxicosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| 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]].
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| A heavy meal has been associated with a 4 fold rise in the risk of [[trigger of MI|MI]], and it is not clear if this is mediated by hyperadrenergic tone<ref name="pmid15609883">{{cite journal |author=Lipovetzky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS |title=Heavy meals as a trigger for a first event of the acute coronary syndrome: a case-crossover study |journal=Isr. Med. Assoc. J. |volume=6 |issue=12 |pages=728–31 |year=2004 |month=December |pmid=15609883 |doi= |url=}}</ref>;
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| [[Familial hypercholesterolemia]]
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| [[Disseminated intravascular coagulation]] ([[DIC]])
[[Hypercoagulable states]]
[[Polycythemia vera]]
[[Thrombocytosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| [[Epinephrine]] overdose
Sudden withdrawal of [[Beta blockers]] or [[nitrates]]
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| A recent [[upper respiratory tract infection]]s has been associated with a 4.9 fold rise in the risk of [[trigger of MI|MI]]
[[Infectious endocarditis]] may STEMI as a result of embolization
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
|bgcolor="Beige"| A heavy meal has been associated with a 4 fold rise in the risk of [[trigger of MI|MI]] and it is not clear if this is mediated by hyperadrenergic tone<ref name="pmid15609883">{{cite journal |author=Lipovetzky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS |title=Heavy meals as a trigger for a first event of the acute coronary syndrome: a case-crossover study |journal=Isr. Med. Assoc. J. |volume=6 |issue=12 |pages=728–31 |year=2004 |month=December |pmid=15609883 |doi= |url=}}</ref>;
[[Amyloidosis]]
[[Fabry disease]]
[[Homocystinuria]]
[[Mucopolysaccharidoses]] or [[Hurler disease]]
[[Pseudoxanthoma elasticum]]
[[Thiamine deficiency]] has been associated with ST elevation and myonecrosis <ref name="pmid16020883">{{cite journal |author=Kawano H, Koide Y, Toda G, Yano K |title=ST-segment elevation of electrocardiogram in a patient with Shoshin beriberi |journal=Intern. Med. |volume=44 |issue=6 |pages=578–85 |year=2005 |month=June |pmid=16020883 |doi= |url=http://joi.jlc.jst.go.jp/JST.JSTAGE/internalmedicine/44.578?from=PubMed}}</ref> <ref>Hundley JM, Ashburn LL, Sebrell WH. The electrocardiogram in chronic thiamine deficiency in rats. Am J Physiol 144: 404–414, 1954. </ref>  <ref name="pmid7197132">{{cite journal |author=Read DH, Harrington DD |title=Experimentally induced thiamine deficiency in beagle dogs: clinical observations |journal=Am. J. Vet. Res. |volume=42 |issue=6 |pages=984–91 |year=1981 |month=June |pmid=7197132 |doi= |url=}}</ref>
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| Spontaneous coronary [[dissection]] in the setting of [[pregnancy]]
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| [[Radiation therapy]] can accelerate atherosclerosis particularly in the distribution of the left anterior descending artery;
|-
|-bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|bgcolor="Beige"| [[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]].
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| 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.
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| A recent [[upper respiratory tract infection]]s has been associated with a 4.9 fold rise in the risk of [[trigger of MI|MI]]
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"| [[Homocystinuria]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"| Takayasus
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| Sexual activity has been identified as a [[trigger of MI]]
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| Both penetrating and non-penetrating trauma to the heart or [[myocardial contusion]], [[commotio cordis]] can be associated with ST elevation and myonecrosis.
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| [[Hypotension]] particularly if it is prolonged
|-
|}


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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{{WikiDoc Sources}}
[[Category:Disease]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Cardiology]]
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[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Mature chapter]]
[[Category:Mature chapter]]
{{WikiDoc Help Menu}}
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Latest revision as of 00:16, 30 July 2020

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][3]

In Alphabetical Order

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 hyper-adrenergic tone[4];
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 hyper-adrenergic tone[4];

Amyloidosis

Fabry disease

Homocystinuria

Mucopolysaccharidoses or Hurler disease

Pseudoxanthoma elasticum

Thiamine deficiency has been associated with ST elevation and myonecrosis [5][6][7]

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 hyper-adrenergic 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 hyper-adrenergic 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:[8]

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 Dissection • Acute Coronary Syndrome • (unstable angina) • (non ST elevation MI) • (ST elevation MI) • Aortic Aneurysm • Aortic Stenosis • Arryhthmias • Bland-White-Garland Syndrome • Chronic Stable Angina • Cor pulmonale • Coronary Heart Disease • Dressler's syndrome (postpericardiotomy) • Hypertrophic Cardiomyopathy • Mitral valve prolapse • Myocardial infarction • Myocarditis • Pericardial tamponade • Pericarditis • Takotsubos cardiomyopathy • Stress 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 • Achalasia • Abdominal distension • Barret’s esophagus • Carcinoma • Cholecystitis • Cholelithiasis • Diverticulitis • Duodenitis • Esophageal rupture • Esophageal spasm • Esophagitis • Foreign body • Gastritis • Gastroesophageal reflux (GERD) • Hiatus Hernia • Impacted stone • Liver abscess • Mallory-Weiss Syndrome • Neoplasm • Nutcracker's esophagus • Pancreatitis • Peptic ulcer disease • Perforated ulcer • Plummer-Vinson Syndrome • Pneumoperitoneum • Splenic enlargement • Splenic infarction • Subdiaphragmatic abcsess • Subphrenic abscess • Whipple's Disease
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease • Bornholm disease • Hepatitis • HIV infection • Herpes Zoster
Musculoskeletal / Ortho • Bechterew's Disease • Bone tumor • Chest wall injuries • Chest wall pain syndrome • Costochondritis • Chosto condral tendinitis • Chosto sternal tendinitis • Tietze's syndrome • CS/TS osteochondrosis • Fibromyalgia • Fractured rib • Intercostal muscle spasm • Interstitial fibrosis • Intercostal neuralgia • Muscle strain or spasm • Myofascial pain • Myostitis • Neuritis • Radiculitis • Periostitis • Precordial catch syndrome • Shoulder bursitis • Shoulder tendinitis • Soft tissue sarcoma or tumor • Sternoclavicular arthritis • Strain of pectoralis muscle • Thoracic Outlet Syndrome • Trauma • Vertebrogenic thoracic pain
Neurologic • Tabes dorsalis
Nutritional / Metabolic No underlying causes
Oncologic • Liver cancer • Mesothelioma • Metastatic tumor • Neurofibroma • Pheochromocytoma
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric • Anxiety disorders • Affective disorders (e.g., depression) • Da costa's syndrome • Thought disorders (e.g., fixed delusions) • Hyperventilation syndrome • Hypochondria • Factitious disorders (e.g. Münchausen syndrome • Fabricated or induced illness • Hospital addiction syndrome) • Panic attack • Somatoform disorders • Somatization disorder
Pulmonary • Asthma • Bronchial carcinoma • Bronchiectasis • Bronchogenic carcinoma • Carcinomatous • Pleural Effusion • Chronic Obstructive Pulmonary Disease (COPD) • Empyema • Hemothorax • Lung Abscess • Lung Cancer • Lymphoma • Mediastinitis • Pleuritis • Pleurodynia • Pneumomediastinum • Pneumonia • Pneumothorax • Pulmonary Embolism • Pulmonary Infarction • Tension pneumothorax • Thymoma • 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 Fever • Peritonitis • Pott's Disease • Xyphodenia

By Alphabetical Order

References

  1. ↑ Tamis-Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM; et al. (2019). "Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association". Circulation: CIR0000000000000670. doi:10.1161/CIR.0000000000000670. PMID 30913893.
  2. ↑ Wang K, Asinger RW, Marriott HJ (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. Unknown parameter |month= ignored (help)
  3. ↑ Ako J, Honda Y, Fitzgerald PJ (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. Unknown parameter |month= ignored (help)
  4. ↑ 4.0 4.1 Lipovetzky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS (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. Unknown parameter |month= ignored (help)
  5. ↑ Kawano H, Koide Y, Toda G, Yano K (2005). "ST-segment elevation of electrocardiogram in a patient with Shoshin beriberi". Intern. Med. 44 (6): 578–85. PMID 16020883. Unknown parameter |month= ignored (help)
  6. ↑ Hundley JM, Ashburn LL, Sebrell WH. The electrocardiogram in chronic thiamine deficiency in rats. Am J Physiol 144: 404–414, 1954.
  7. ↑ Read DH, Harrington DD (1981). "Experimentally induced thiamine deficiency in beagle dogs: clinical observations". Am. J. Vet. Res. 42 (6): 984–91. PMID 7197132. Unknown parameter |month= ignored (help)
  8. ↑ Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal. 17 (7): 1028–34. PMID 8809520. Retrieved 2012-05-02. Unknown parameter |month= ignored (help)

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