ST elevation myocardial infarction differential diagnosis

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:

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
• 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 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-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;
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; Amyloidosis Fabry disease Homocystinuria Mucopolysaccharidoses or Hurler disease Pseudoxanthoma elasticum Thiamine deficiency has been associated with ST elevation and myonecrosis
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

• Aortic dissection
• Esophageal rupture
• Myocardial infarction
• Pulmonary embolism
• Tension pneumothorax

The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is:

• 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

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 Alphabetical Order

• Actinomycosis
• Acute intermittent porphyria
• Adenosine
• Amonafide
• Anemia
• Ankylosing spondylitis
• Aortic valve stenosis
• Arsenic trioxide
• Arsenicals
• Blood transfusion and complications
• Bornholm disease
• Bronchogenic cyst
• Carbon monoxide toxicity
• Cardiomyopathy
• Familial hypertrophic cardiomyopathy
• Cardiopulmonary resuscitation
• Coronary artery dissection
• Diffuse esophageal spasm
• Dissecting aortic aneurysm
• Dressler syndrome
• Pleural empyema
• Esophageal achalasia
• Esophageal cyst
• Fabry disease
• Functional disorders
• Gastric ulcer
• Gastroesophageal reflux
• Gemeprost
• Glatiramer acetate
• Glycogenosis type 7
• Ischaemic heart disease
• Kawasaki disease
• Left ventricular hypertrophy
• Lymphangiomyomatosis
• Mediastinitis
• Mesothelioma
• Mitral valve prolapse
• Myocardial infarction
• Myocarditis
• Naratriptan
• Nylidrin
• Esophageal foreign body
• Esophageal rupture
• Esophagitis
• Pericarditis
• Pleural effusion
• Pleural fibroma
• Pleuritis
• Pneumonia
• Pneumothorax
• Porfimer
• Prinzmetal angina
• Pulmonary embolism
• Pulmonary infarction
• Quaternary syphilis
• Recurrent hereditary polyserositis
• Regadenoson
• Respiratory alkalosis
• Rib fracture
• Rib pain
• Rizatriptan
• Rumination disorder
• SAPHO syndrome
• Shingles
• Sickle cell crisis (thrombotic)
• Sickle cell disease
• Acute spinal cord injury
• Subdiaphragmatic abscess
• Sumatriptan
• Syndrome X
• Tabes dorsalis
• Takotsubo cardiomyopathy
• Tension pneumothorax
• Thallium
• Thyroiditis
• Tietze costochondritis
• Trichinella spiralis
• Unstable angina
• Varicella-zoster virus
• Wegener granulomatosis
• Zolmitriptan

References

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