ST elevation myocardial infarction differential diagnosis
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ST Elevation Myocardial Infarction Microchapters |
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Differentiating ST elevation myocardial infarction from other Diseases |
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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 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.
Complete Differential Diagnosis of Chest Pain
By Organ System
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
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]
Listed in Alphabetical Order
- Aneurysm of the ventricle can result in persistent ST segment elevation that can be exacerbated with tachycardia.
- Balloon inflation in a coronary artery during percutaneous coronary intervention
- 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.
- 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.
- Stroke Intracranial hemorrhage 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-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 |
| 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 hyperadrenergic tone[3]; |
| Genetic | Familial hypercholesterolemia |
| Hematologic | Disseminated intravascular coagulation (DIC) |
| 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 hyperadrenergic tone[3];
Mucopolysaccharidoses or Hurler disease Thiamine deficiency has been associated with ST elevation and myonecrosis [4] [5] [6] |
| 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 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. |
| 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 |
References
- ↑ 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) - ↑ 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) - ↑ 3.0 3.1 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) - ↑ 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) - ↑ Hundley JM, Ashburn LL, Sebrell WH. The electrocardiogram in chronic thiamine deficiency in rats. Am J Physiol 144: 404–414, 1954.
- ↑ 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)