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Acute Myocardial Infarction Presenting with Pharyngeal Pain Alone
The Journal of Emergency Medicine, Vol. 43, No. 5, pp. e287ee288, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2010.05.028
Clinical Communications: Adults ACUTE MYOCARDIAL INFARCTION PRESENTING WITH PHARYNGEAL PAIN ALONE Youichi Yanagawa, MD, PHD,* Masahiko Nishimura, EMT,† Jihei Ohkawara, EMT,† Kotaro Hasegawa, MD,‡ and Masahisa Yamane, MD, PHD‡ *Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan, †Tokorozawa City Fire Department Headquarters, Tokorozawa, Saitama, Japan, and ‡Department of Cardiology, Sayama Hospital, Sayama, Saitama, Japan Reprint Address: Youichi Yanagawa, MD, PHD, Department of Traumatology and CCM, NDMC, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
, AbstractdBackground: Pharyngeal pain alone due to acute myocardial infarction is rare. Case Report: A 37year-old man felt sudden pharyngeal pain. He was transferred to a medical facility under a misdiagnosis of pharyngitis. However, he was thereafter found to have acute myocardial infarction and thus was transferred to another hospital. An emergency coronary angiogram revealed complete occlusion of the right coronary artery and he underwent coronary angioplasty. The patient was later discharged ambulatory. Conclusion: A misdiagnosis of acute myocardial infarction can lead to unfavorable outcomes; therefore, physicians or emergency medical technicians should be aware of this disease even when a patient complains of sudden pharyngeal pain alone. Ó 2012 Elsevier Inc.
CASE REPORT A 37-year-old man felt sudden pharyngeal pain while watching television and called an ambulance. Emergency medical technicians checked the patient and he complained of pharyngeal pain alone in a supine position, and his body was covered with perspiration. He did not have any risk factors for atherosclerosis, such as diabetes mellitus, tobacco smoking, hypertension, or obesity. He also had never taken such drugs as cocaine. His vital signs were: blood pressure 102/54 mm Hg, pulse rate 66 beats/ min regularly, respiratory rate 26 breaths/min, and tympanic temperature 35.2 C. He was transferred to a medical facility under a misdiagnosis of pharyngitis made by the emergency medical technicians. However, an electrocardiogram revealed acute myocardial infarction and he was transferred to another hospital that had a coronary care unit. On arrival at the second hospital he showed clear consciousness, and his vital signs were: blood pressure 100/70 mm Hg, pulse rate 37 beats/min regularly, respiratory rate 24 breaths/min, and tympanic temperature 35.2 C. The physical examination was negative, including the oral cavity. Electrocardiogram exhibited an ST elevation in II, III, and aVF, and ST depression in I, aVL, and V1eV4 (Figure 1). A chest radiograph study was negative. The results of the biochemical analyses of the blood suggested acute myocardial infarction (troponin I 0.10 ng/mL [< 0.09] and creatinine kinase-MB 27.0 U/L
, Keywordsdprehospital care; acute myocardial infarction; pharyngeal pain
INTRODUCTION Pharyngeal pain is usually caused by an inflammation. In contrast, the typical pain with angina is chest discomfort, usually described as heaviness, pressure, squeezing, or choking (1). It can radiate to the left shoulder and to both arms. In some cases, angina pectoris radiates to the pharynx, back, interscapular region, root of the neck, jaw, teeth, and epigastrium (1). However, angina pectoris with only pharyngeal pain is rare. This report presents the case of a patient with acute myocardial infarction that presented with pharyngeal pain alone.
RECEIVED: 23 January 2010; FINAL SUBMISSION RECEIVED: 1 April 2010; ACCEPTED: 17 May 2010 e287
e288
Y. Yanagawa et al.
Figure 1. Electrocardiogram on arrival. The electrocardiogram exhibits an ST elevation in II, III, and aVF, and ST depression in I, aVL, and V1eV4.
[< 25.0]). An emergency coronary angiogram revealed complete occlusion of the right coronary artery and 50% stenosis of the left main trunk; and subsequent angioplasty for the right coronary artery resulted in complete recanalization, but required post-procedure intra-aortic balloon pumping to treat the patient’s unstable circulation. After these procedures his pharyngeal pain improved, so we judged that his pharyngeal pain was actually a cardiac ischemic episode. He experienced ventricular flutter tachycardia on the second hospital day, which was successfully treated with nifekalant (a potassium channel blocker). The patient’s hemodynamics improved and the intra-aortic balloon pump could be removed from the patient on the fourth hospital day. After obtaining stable circulation and confirmation of patency of the right coronary artery, additional angioplasty was performed for the residual left main trunk of the coronal artery. The patient was discharged on foot on the tenth hospital day.
heart disease. Auer et al. and Sone et al. also reported cases with pharyngeal or throat pain alone induced by ischemic heart disease (3,4). Pharyngeal pain alone due to acute myocardial infarction is rare. However, a misdiagnosis of acute myocardial infarction can lead to unfavorable outcomes, so physicians or emergency medical technicians should be aware of this disease even when a patient complains of sudden pharyngeal pain alone and has no remarkable pharyngeal abnormality (5).
DISCUSSION
REFERENCES
Craniofacial pain can be the only symptom of cardiac ischemia. Kreiner et al. prospectively selected consecutive patients (n = 186) who had had a verified cardiac ischemic episode (2). Craniofacial pain was the only complaint during the cardiac ischemic episode in 11 patients (6%) with ischemic heart disease, 3 of whom (1.6%) had acute myocardial infarction. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region, and teeth. In the absence of chest pain, the craniofacial area seems to be the most prevalent location of pain induced by ischemic
CONCLUSION A misdiagnosis of acute myocardial infarction can lead to unfavorable outcomes, so physicians or emergency medical technicians should be aware of this disease even when a patient complains of sudden pharyngeal pain alone.
1. Selwyn AP, Braunwald E. Ischemic heart disease. In: Kasper D, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s principles of internal medicine. 16th edn. New York: McGraw-Hill; 2005:1434e44. 2. Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. J Am Dent Assoc 2007;138:74e9. 3. Auer J, Weber T, Berent R, et al. Throat pain as the only symptom of inferior wall myocardial infarction. J Otolaryngol 2006;35:424e6. 4. Sone M, Koizumi A, Tamiya E, et al. Angina pectoris with pharyngeal pain alone: a case report. Angiology 2009;60:259e61. 5. Brieger D, Eagle KA, Goodman SG, et al., GRACE Investigators. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest 2004;126:461e9.
doi:10.1016/j.jemermed.2010.05.028
Clinical Communications: Adults ACUTE MYOCARDIAL INFARCTION PRESENTING WITH PHARYNGEAL PAIN ALONE Youichi Yanagawa, MD, PHD,* Masahiko Nishimura, EMT,† Jihei Ohkawara, EMT,† Kotaro Hasegawa, MD,‡ and Masahisa Yamane, MD, PHD‡ *Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan, †Tokorozawa City Fire Department Headquarters, Tokorozawa, Saitama, Japan, and ‡Department of Cardiology, Sayama Hospital, Sayama, Saitama, Japan Reprint Address: Youichi Yanagawa, MD, PHD, Department of Traumatology and CCM, NDMC, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
, AbstractdBackground: Pharyngeal pain alone due to acute myocardial infarction is rare. Case Report: A 37year-old man felt sudden pharyngeal pain. He was transferred to a medical facility under a misdiagnosis of pharyngitis. However, he was thereafter found to have acute myocardial infarction and thus was transferred to another hospital. An emergency coronary angiogram revealed complete occlusion of the right coronary artery and he underwent coronary angioplasty. The patient was later discharged ambulatory. Conclusion: A misdiagnosis of acute myocardial infarction can lead to unfavorable outcomes; therefore, physicians or emergency medical technicians should be aware of this disease even when a patient complains of sudden pharyngeal pain alone. Ó 2012 Elsevier Inc.
CASE REPORT A 37-year-old man felt sudden pharyngeal pain while watching television and called an ambulance. Emergency medical technicians checked the patient and he complained of pharyngeal pain alone in a supine position, and his body was covered with perspiration. He did not have any risk factors for atherosclerosis, such as diabetes mellitus, tobacco smoking, hypertension, or obesity. He also had never taken such drugs as cocaine. His vital signs were: blood pressure 102/54 mm Hg, pulse rate 66 beats/ min regularly, respiratory rate 26 breaths/min, and tympanic temperature 35.2 C. He was transferred to a medical facility under a misdiagnosis of pharyngitis made by the emergency medical technicians. However, an electrocardiogram revealed acute myocardial infarction and he was transferred to another hospital that had a coronary care unit. On arrival at the second hospital he showed clear consciousness, and his vital signs were: blood pressure 100/70 mm Hg, pulse rate 37 beats/min regularly, respiratory rate 24 breaths/min, and tympanic temperature 35.2 C. The physical examination was negative, including the oral cavity. Electrocardiogram exhibited an ST elevation in II, III, and aVF, and ST depression in I, aVL, and V1eV4 (Figure 1). A chest radiograph study was negative. The results of the biochemical analyses of the blood suggested acute myocardial infarction (troponin I 0.10 ng/mL [< 0.09] and creatinine kinase-MB 27.0 U/L
, Keywordsdprehospital care; acute myocardial infarction; pharyngeal pain
INTRODUCTION Pharyngeal pain is usually caused by an inflammation. In contrast, the typical pain with angina is chest discomfort, usually described as heaviness, pressure, squeezing, or choking (1). It can radiate to the left shoulder and to both arms. In some cases, angina pectoris radiates to the pharynx, back, interscapular region, root of the neck, jaw, teeth, and epigastrium (1). However, angina pectoris with only pharyngeal pain is rare. This report presents the case of a patient with acute myocardial infarction that presented with pharyngeal pain alone.
RECEIVED: 23 January 2010; FINAL SUBMISSION RECEIVED: 1 April 2010; ACCEPTED: 17 May 2010 e287
e288
Y. Yanagawa et al.
Figure 1. Electrocardiogram on arrival. The electrocardiogram exhibits an ST elevation in II, III, and aVF, and ST depression in I, aVL, and V1eV4.
[< 25.0]). An emergency coronary angiogram revealed complete occlusion of the right coronary artery and 50% stenosis of the left main trunk; and subsequent angioplasty for the right coronary artery resulted in complete recanalization, but required post-procedure intra-aortic balloon pumping to treat the patient’s unstable circulation. After these procedures his pharyngeal pain improved, so we judged that his pharyngeal pain was actually a cardiac ischemic episode. He experienced ventricular flutter tachycardia on the second hospital day, which was successfully treated with nifekalant (a potassium channel blocker). The patient’s hemodynamics improved and the intra-aortic balloon pump could be removed from the patient on the fourth hospital day. After obtaining stable circulation and confirmation of patency of the right coronary artery, additional angioplasty was performed for the residual left main trunk of the coronal artery. The patient was discharged on foot on the tenth hospital day.
heart disease. Auer et al. and Sone et al. also reported cases with pharyngeal or throat pain alone induced by ischemic heart disease (3,4). Pharyngeal pain alone due to acute myocardial infarction is rare. However, a misdiagnosis of acute myocardial infarction can lead to unfavorable outcomes, so physicians or emergency medical technicians should be aware of this disease even when a patient complains of sudden pharyngeal pain alone and has no remarkable pharyngeal abnormality (5).
DISCUSSION
REFERENCES
Craniofacial pain can be the only symptom of cardiac ischemia. Kreiner et al. prospectively selected consecutive patients (n = 186) who had had a verified cardiac ischemic episode (2). Craniofacial pain was the only complaint during the cardiac ischemic episode in 11 patients (6%) with ischemic heart disease, 3 of whom (1.6%) had acute myocardial infarction. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region, and teeth. In the absence of chest pain, the craniofacial area seems to be the most prevalent location of pain induced by ischemic
CONCLUSION A misdiagnosis of acute myocardial infarction can lead to unfavorable outcomes, so physicians or emergency medical technicians should be aware of this disease even when a patient complains of sudden pharyngeal pain alone.
1. Selwyn AP, Braunwald E. Ischemic heart disease. In: Kasper D, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s principles of internal medicine. 16th edn. New York: McGraw-Hill; 2005:1434e44. 2. Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. J Am Dent Assoc 2007;138:74e9. 3. Auer J, Weber T, Berent R, et al. Throat pain as the only symptom of inferior wall myocardial infarction. J Otolaryngol 2006;35:424e6. 4. Sone M, Koizumi A, Tamiya E, et al. Angina pectoris with pharyngeal pain alone: a case report. Angiology 2009;60:259e61. 5. Brieger D, Eagle KA, Goodman SG, et al., GRACE Investigators. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest 2004;126:461e9.