Death due to unrecognised myocardial infarction causing left ventricular rupture: can we improve the diagnostic rate?
AIM: To investigate the clinical presentations of ruptured myocardial infarction, where the initial diagnosis of myocardial infarction was missed, to enhance the diagnostic rate of primary care physicians. METHODS: We studied 67 cases of myocardial infarction, terminating with left ventricular rupture, between January 1988 and December 1996. The study was restricted to sudden death where, at coroner-directed autopsy, a ruptured myocardial infarction was determined as the cause of death. It was also restricted to patients who consulted a doctor within the two weeks prior to death. The report made to the coroner by attending police and the autopsy report was studied, and the requisite data were abstracted. RESULTS: Half of our study group did not present with chest pain. Of the atypical presentations: 15/67 cases (22%) were from referred pain (neck, arm, abdomen or back), 12/ 67 patients presented with "flu-like illness" (18%), 4/67 cases had respiratory presentations (cough or shortness of breath) (6%) and 2/67 falls (3%). Of those with chest pain, 16/34 (47%) were diagnosed or referred and 2/15 infarcts with atypical or referred pain were diagnosed. None of those presenting with "flu like illness" or respiratory symptoms was diagnosed or referred. CONCLUSION: Fifty per cent of our patients had "silent" myocardial infarcts. A large proportion of this group complained of a flu-like illness, which is currently not considered a presentation of this disease. Patients at higher risk of a myocardial infarct, should be treated with a high index of suspicion when unwell, especially when complaining of a flu-like illness. Pathologically, posterior and lateral infarcts accounted for over half the cases.