Unusual and very rare presentation of wrist pain in a man with acute anterior myocardial infarction, a case report and literature of review

Abstract

Background

As acute myocardial infarction (AMI) prevalence is increasing because of lifestyle changes, the incidence of atypical symptoms in acute coronary syndrome (ACS) is rising and making misdiagnosing of this fatal event more probable. To better approach the patients with atypical symptoms, we tend to present a rare case of AMI with wrist pain.

Case report

A 41-year-old man presented to the emergency room (ER) with severe both-hand wrist pain and mild epigastric pain. His electrocardiogram (ECG) showed anterior ST-elevation myocardial infarction (MI) with an ejection fraction of 35–40%. His angiography showed severe left anterior descending artery (LAD), and first obtuse marginal artery (OM1) artery stenosis. He underwent Primary percutaneous coronary intervention (PCI). The patient recovered without serious complications and was discharged the day after PCI.

Discussion

In this rare case of AMI with wrist pain, it is important to know that atypical symptoms can be present at various levels of symptoms, which prevents future misdiagnosis.

Introduction

As a rising concern in the field of cardiology, and emergency medicine, acute coronary syndrome (ACS), and acute myocardial infarction (AMI) are the most focused and prevalent complaints in these fields. AMI is considered a leading cause of death in developed countries and developing countries are struggling with this epidemic [1].

As AMI more commonly occurs in men, the symptoms that are available in the studies are more presented by men by typical presentation such as chest pain, cold sweating, and dyspnea. Because of the lack of evidence and data regarding atypical symptoms, which are statistically higher among women, diabetic patients, and other groups, these symptoms may not be diagnosed early enough for treatment [2]. The patients can experience a wide range of unspecific pain and discomfort from the lower jaw to the abdomen while experiencing MI. There are cases reported that the pain was in other uncommon places such as ears, legs, or thighs [2]. The atypical presentation of STEMI is estimated to be about 26–34% [3, 4].

Furthermore, the mortality of patients presenting with atypical symptoms is higher than that of patients presenting with typical pain. In a study, the mortality of these patients was reported to be 20% higher. [1].

Since the misdiagnosis of unusual manifestations, and late referral to the emergency room can lead to fatal cardiovascular outcomes, doctors should consider these factors. To detect rare forms of the disease, it is therefore important to introduce rare atypical symptoms. We introduce a patient with wrist pain in both hands with acute heart infarction.

Case report

A 41-year-old man came to the emergency room with right and left wrist pain and mild epigastric pain. He had no shoulder/arm pain. His wrist pain had started around 11:00 p.m. the night before, the patient did not take it seriously, took acetaminophen, and slept. At around 3:30 a.m., the patient woke up with very severe pain in the wrists of both hands. The pain was severe, but there was no sweating nausea, or vomiting. He had no pain in the chest area, back, or other parts of his hands. After experiencing pain in both wrists and a mild burning sensation in the epigastrium at 4:30 a.m., he went to Valiasr Hospital, the surgical center for digestive problems, for emergency treatment. Due to the epigastric pain, a routine ECG was done and although the patient did not mention any past medical history of trauma, our differential diagnosis for wrist pain was fracturs and ischemic or thrombotic events related to the wrist pain although after further examination they had been ruled out. ECG was taken from the patient, and acute anterior STEMI was diagnosed with Troponin-I positive, so the patient was transferred to Razi Birjand Hospital (at 4:45 a.m.), which is PCI-capable. The patient’s vital signs were stable as follows; Blood pressure; 128/76mmhg, pulse rate: 80 per minute, respiratory rate per 16-minute, temperature: 37.20 C, and oxygen saturation (spO2): 97%. He only had a history of hypertension and no history of heart disease in his family. He smokes cigarettes occasionally. In the clinical examinations, heart and lung auscultation were normal. His laboratory data were: triglyceride of 45 mg/dl, low -density lipoprotein (LDL) of 100 mg/dl, high-density lipoprotein (HDL) of 40 mg/dl, total cholesterol of 167 and fasting blood sugar (FBS) of 105 mg/dl.

His ECG showed ST elevation in V1 to V3 and ST depression in lead II, III, and AVF (Fig. 1). His echocardiography indicated an ejection fraction (EF) of 35 to 40% with thinning of the anteroseptal wall, and hypokinesia in the anterior, anteroseptal, and anterolateral walls. He received 600 mg of clopidogrel, 80 mg of atorvastatin, and 300 mg of chewable aspirin.

Fig. 1

ECG of the patient upon entering to emergency room. Depression of ST in II, III, and AVF. Elevation of ST in V1 to V3 with hyperacute T wave

He was transferred to the Catheterization Laboratory at 5:50 am (80 min after entering the emergency room). A coronary angiography was performed using the right radial artery at that time. The results of angiography indicated a thrombotic lesion in the mid portion of the left anterior descending artery (LAD) with 90–99% stenosis in OM1 (Fig. 2). The syntax score was 17.5, and therefore Primary PCI was performed on the LAD and OM1 successfully (ECG post PCI, Fig. 3). The patient had an anterior AMI and angiography showed a thrombotic lesion in LAD, primary PCI for the culprit lesion was performed. According to the European Society of Cardiology (ESC) guidelines, and because the patient was not in cardiogenic shock, PCI was also performed on the OM [5].The patient was transferred to CCU at 7:23 a.m. The next day, he was discharged in a stable condition with medical treatment (ECG at discharge, Fig. 4). Currently, 4 months after the incident, the patient has no symptoms and is undergoing cardiac rehabilitation.

Fig. 2

Patient’s angiography (before and after performing PCI)

Fig. 3

ECG of the patient after the PCI procedure. Elevation of ST in V2 and V3, no ST depression in inferior leads

Fig. 4

ECG of the patient 1 day after the MI (at discharge day). T wave inverted in precordial leads, no ST elevation or Depression

Discussion and literature review

Based on the review of the literature, it seems that this is the first case report about” a patient with wrist pain and AMI”. A young man with a history of hypertension and pain in the wrists went to the emergency room about 5 h after the onset of symptoms, and this delay caused a decrease in EF. Our patient had wrist pain since 11:30 at night and did not pay attention to it. Even though the symptoms were severe at 3:30 in the morning, he didn’t think there was anything serious wrong. Later, he felt a slight burning sensation in the epigastrium and went to the hospital for a gastrointestinal examination. This delay was about 5 h. The patient’s description of his pain is very interesting, “I felt that my wrists were about to explode. This condition started at 3:30 a.m. It didn’t get better after taking sublingual nitroglycerin and injecting intravenous morphine, but after performing PCI, I got relief from this pain”.

Although the majority of AMI cases are characterized by typical chest pain, which may radiate to the arms, back, and lower jaw, a significant percentage of individuals come with atypical MI presentation [6, 7]. The condition of acute myocardial infarction can sometimes manifest in diverse and strange ways, as in the case of our patient suffering from wrist pain, which doctors and nurses need to be aware of. Based on epidemiological studies, about 26–34% of patients with AMI have atypical symptoms [3, 4]. The presence of atypical symptoms causes a late referral of patients to the emergency room, delays in diagnosis and treatment (especially early reperfusion), and higher mortality of patients. This failure in immediate diagnosis and treatment increases the possibility of arrhythmia, cardiac arrest, heart failure, and sudden death [6]. Figure 5 is an illustration of AMI pain distribution based on various studies [2, 8].

Fig. 5

pain distribution of acute myocardial infarction

Several studies estimated that atypical symptoms are more prevalent in older adults, female gender, non-white races, and non-ST elevation MI (NSTEMI) patients, as well as in patients with comorbid factors, such as diabetes mellitus, hypertension, chronic kidney disease, and a history of stroke, congestive heart failure, prior STEMI, and revascularization (PCI or CABG) [7, 9,10,11].

In the systematic analysis, Khan. et al. estimated that gastrointestinal symptoms (21.43%), and throat pain (10.71%) are among the top atypical symptoms reported in STEMI case reports. And otalgia was among the atypical symptoms (8.7%) [2]. A study was conducted on the location of pain radiation on 541 patients with acute coronary syndrome. The participants were instructed to mark the location of their discomfort on a body map; in contrast to males who had STEMI, women reported experiencing pain more intensely in their right arm/shoulder and front neck [13]. The nearest case to this case in a matter of the region of pain is a case report from 1940 reporting a 56-year-old male with wrists and elbows pain in the flexor region which relives by resting. One year later he experienced a typical angina. His ECG demonstrated an inverted T wave in leads V2 and V3 and a prominent Q in V3 [12]. Further in this case series, there are cases of wrist, shoulder forearm, and upper arm pain which were reported as cardiac infractions or typical angina [12]. But still, there is no case of wrist pain related to an AMI. It is known that the vagus nerve carries the referral pain to the craniofacial region. For instance, a rare case of AMI in an 87-year-old woman presenting with otalgia and head and neck sweating with a history of diabetes indicated severe coronary artery stenosis. similar cases were reported in this area and are even more common in females and diabetic patients [13].

Based on our current understanding, this case of wrist pain in an AMI patient is unprecedented and has not been previously attributed to any physiological mechanism. Cardiac pain can be transmitted by afferent vagal and sympathetic nerves in response to myocardial ischemia [14]. The first five sympathetic roots of the thoracic transmit most of the cardiac pain [15]. Sympatic nerves innervate the heart by thoracic ganglions (superior, middle, and inferior cervical ganglions) which are connected to the C4 to C8 roots. These roots also give rise to the radial nerve (C5 to T1), median nerve (C6 to T1), and (C8 to T1) nerve which are responsible for wrist pain [16]. Somatic and visceral afferents converge on the same neurons in the CNS, causing pain in specific locations [17].

Even though this was an uncommon instance involving a male patient, the significance of this case report should be considered to ensure that patients coming with unusual discomfort are appropriately diagnosed. Regarding previous reviews, the statistics indicate about 1 to 2% of AMI cases remain misdiagnosed mainly in terms of atypical presentation and misinterpretation of the ECG (23).

Conclusion

As the rising epidemiology of AMI in terms of lifestyle and diabetes is one of the factors in atypical presentations, the importance of distinguishing AMI patients with rare symptoms is constantly rising. Familiarity with less presented symptoms helps physicians and cardiologists in better practice and preventing misdiagnosis of this fatal disease.

Strengths and weaknesses

As this study states a rare presentation of AMI the findings are new and are useful for future physicians to better manage the AMI cases with rare presentation. Our study includes the possible mechanism of this phenomenon which to our knowledge has not been discussed before. There were some limitations and weaknesses in our management of patients. The 5-hour delay of PCI due to the transferring of the patient and the rarity of the presentation should be taken into account for future encounters. The lack of physiological and anatomical data on this matter is sensible and therefore we need future studies to better elaborate on related mechanisms of pain in such referral pains.