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I./4.2.: Symptomatology
Acute myocardial infarction is an acute disease and therefore the symptoms begin suddenly in the decisive majority (but not in all!) of cases. Stable angina pectoris is present among the previous complaints of patients only in approximately a half of the cases. Initial (prodromal) symptoms, immediately preceding the infarction are uncommon and uncharacteristic such as chest discomfort, possibly fatigue or lethargy. In a typical case the leading symptom is a suddenly beginning intense retrosternal pain of pressing nature. The pain often radiates, typically into the back, to the left (maybe both) arm(s) or to the neck and chin. In patients with an acute myocardial infarction with an inferior localization the pain frequently occurs in the epigastric region which localization may unfortunately misguide the diagnosis, suggesting mostly the erroneous presumption of a gastrointestinal disease (reflux, peptic ulcer, gastroenteritis, cholelithiasis).
In a not negligible part of cases the pain may be lacking partly or totally; primarily in elderly patients or in patients with diabetes mellitus due to the autonomic neuropathy which developed as a complication of their diabetes. The pain may be accompanied by autonomic symptoms including weakness, pallor, sweating, nausea, an urge to vomit, vomiting or possibly fear of death. In case of a timely performed successful reperfusion therapy, mostly a primary percutaneous coronary intervention, the pain promptly ceases upon the termination of coronary occlusion, yet in the operating table. In patients with a largely extended infarction and consecutive significant reduction of left ventricular function or in those who develop mechanical complications (e.g. rupture of the mitral papillary muscle) shortness of breath, dyspnea, orthopnea may occur.
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In the most serious cases a state of cardiogenic shock develops with signs and symptoms including a systolic blood pressure under 100 mmHg (or a fall of at least 30 mmHg from the previous high one!), paleness, disordered peripheral circulation, cool extremities, oliguria, and disordered consciousness. Physical examination reveals tachycardia and congestion over a part of the lungs or the whole pulmonary area. The degree of heart failure associated with an acute myocardial infarction is categorized on the base of a physical examination according to the Killip classification: Stage I: „dry-warm” (= no congestion, the skin is warm) – Stage II: congestion over the pulmonary bases – Stage III: congestion over the whole pulmonary area – Stage IV: „wet-cool”: congestion and cardiogenic shock.
In patients with a mechanic complication such as dysfunction/rupture of the apparatus holding the mitral valve (Image 1) a loud holosystolic murmur appears in the area of the left ventricle. In patients with a rupture of the ventricular septum a holosystolic murmur is heard on both sides of the sternum. The rupture of a free ventricular wall causes pericardial tamponade, shock and then a collapse of the circulation. (Image 2) An exact diagnosis can be established by echocardiography. (Image 3) In the most severe cases the first (and in a bad case the last) symptom is the sudden death, as malignant arrhythmia, mostly ventricular fibrillation, develops due to the acute myocardial infarction.
Primarily an inferior infarction may cause bradycardia, conduction disorder with the corresponding symptoms including circulatory collapse in the most severe cases and dizziness, intense weakness, pallor, confusion, overlaid consciousness in the less severe cases. In elderly patients and in those with diabetes mellitus the symptoms may differ; particularly the chest pain may be absent. Especially the elderly patients are characterized by a collapse and weakness with no chest pain, and therefore it is not sufficient to count their heart rate when observing such symptoms; an ECG should also be performed.
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