The presentation of an apical myocardial infarction patient depends on whether the disease is acute or chronic. Acute patients have the usual complaints of cardiac ischemia patients. A strictly apical location implies that the mass of the affected myocardial tissue is relatively small, therefore the patient is unlikely to present in cardiogenic shock, but rather be a Killip class I case, with no evidence of heart failure. Pulmonary edema presentation is also unlikely. In return, the patient complains of chest pain that often radiates to the epigastrium or malaise. The pain is severe and lasts for 30 to 60 minutes. The character of the disease is different in different individuals, being described as a squeezing, burning, pressure, aching or sharp sensation. In other cases, myocardial ischemia can go unrecognized, as the patient believes he or she is suffering from indigestion or has no complaints whatsoever. This latter situation is more frequently seen in diabetes, dementia or elderly patients. Symptoms are more frequent during the early morning hours [1].

Patients with a previous apical myocardial infarction may have heart failure signs if the acute event was not strictly apical, but involved significant parts of neighboring walls and was complicated by aneurysm formation that occupies a significant ventricular territory. The anterior wall is more frequently implicated than the inferior and posterior ones.

• Coronary Atherosclerosis

  Role of endothelial shear stress in the natural history of coronary atherosclerosis and vascular remodeling: molecular, cellular, and vascular behavior. J Am Coll Cardiol. 2007 Jun 26. 49(25):2379-93. [Medline]. [emedicine.medscape.com]

• Chest Pain

  Case Presentation: A 29 year old African American male presented with non-radiating, mid-sternal chest pain, which was relieved by sitting up. His vital signs and physical examination were unremarkable. [shmabstracts.com]

  A 51-year-old Japanese woman consulted the emergency room complaining of the sudden onset of anterior chest pain while shopping. [ncbi.nlm.nih.gov]

  A 66-year-old female presented to the emergency room with an episode of chest pain that lasted for a few minutes before resolving spontaneously. [hindawi.com]

  In return, the patient complains of chest pain that often radiates to the epigastrium or malaise. The pain is severe and lasts for 30 to 60 minutes. [symptoma.com]

• Heart Disease

  Acute and Stable Ischemic Heart Disease: Clinical Presentation Number: 1297-316 2017 American College of Cardiology Foundation [onlinejacc.org]

  Myocardial Infarction: A Companion to Braunwald’s Heart Disease, by David A. Morrow, MD, is a comprehensive, hands-on resource that provides practical guidance from a name you trust. [books.google.com]

  Coronary: · failure · insufficiency I24.9 Acute ischaemic heart disease, unspecified Excludes: ischaemic heart disease (chronic) NOS ( I25.9 ) I25 Chronic ischaemic heart disease Excludes: cardiovascular disease NOS ( I51.6 ) I25.0 Atherosclerotic cardiovascular [apps.who.int]

  Diagnosis Ischemic heart disease is typically associated with an underlying specific heart disease. In “stable” angina, chest pain with typical features occurs at predictable levels of exertion. [courses.lumenlearning.com]

  Our Specialty Centers The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease takes a multidisciplinary approach to helping you prevent heart disease and stroke—and that includes getting your cholesterol in check. [hopkinsmedicine.org]

• Retrosternal Chest Pain

  The overall incidence is unknown, although it may be more prevalent than currently reported.(2) Although retrosternal chest pain is the most common symptom, some patients exhibit dyspnea, shock, or electrocardiographic alterations.(3) By definition, Takotsubo [scielo.br]

• Short Neck

  It was first described by Satoh et al. (1) and Dote et al. (2) and was named “Takotsubo”-shaped cardiomyopathy due to its unique “short neck round-flask”-like LV apical ballooning resembling the tako-tsubo (Japanese for octopus pot or trap) of Japan. [onlinejacc.org]

The first step in addressing a non-critical myocardial infarction patient should be obtaining the history of the disease and assessing risk factors [2] [3]. Clinical examination should assess the skin (color and presence of diaphoresis), blood pressure, pulse (frequency, rhythm and equality in similar territories), heart and breathing sounds, the presence of gastrointestinal symptoms such as nausea and vomiting, neck vein aspect, temperature (fever is present during the first two days of evolution [4]) and urinary output.

Once the suspicion of an acute myocardial infarction is raised, electrocardiography is usually the first investigation performed. As discussed above, the apical localization is rather difficult to define by this method, but modifications do appear in contiguous leads.

The electrocardiogram also detects newly installed branch blocks, also an indicator of ischemia, and potentially life-threatening arrhythmias [5] [6].

The protocol states that cardiac enzymes (troponin, myoglobin and creatine kinase) should be measured in a serial manner [7] [8]. Recent guidelines advise that high-sensitive troponin I or troponin T assays should be used [9] [2]. Brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide is only useful in chronic myocardial infarction patients for risk stratification and heart failure prognosis [10] [11].

The exact localization of the infarction area is stated by imaging methods. Echocardiography is a useful, readily available and reliable method that helps to evaluate wall motion abnormalities. Multidetector computed tomography and single-photon emission CT (SPECT) or positron emission tomography (PET) scanning, although viable methods, are not routinely used in triage settings, but are useful in detecting ventricular aneurysms [12]. Classic coronary catheterization has the advantage of offering clear diagnosis and being a therapeutic procedure, as well.

• Inferior Q Wave

  Q Waves - not Old Inferior Wall Myocardial Infarction (MI) ECG Old Inferior Wall Myocardial Infarction (MI) ECG (Example 1) Old Inferior Wall Myocardial Infarction (MI) ECG (Example 2) Posterior Wall Myocardial Infarctions Inferior-Posterior Wall Myocardial [healio.com]

• ST Elevation

  In the acute period (6 9 h; range, 1 to 48 h), ST elevation was observed in 79 (90%) of the patients, including four patients with solitary ST elevation of limb-lead and 13 patients without right precordial (V 1, V 2 ) ST elevation. [onlinejacc.org]

  The aim of the work was to assess apical rotation in acute ST-elevation MI. [mmj.eg.net]

  He was treated as an acute ST-elevation myocardial infarction with thrombolytics. There was no cardiac biomarker rise and coronary angiography did not reveal evidence of significant coronary arterial disease. [readbyqxmd.com]

  Overnight, his subsequent EKG showed diffuse ST elevation and PR segment depression suggestive of pericarditis, and he was started on colchicine and NSAIDs. However, his chest pain did not resolve. His CRP was 0.2 mg/dL and ESR was 2 mm/hr. [shmabstracts.com]

1. Wijnbergen I, Van't Veer M, Pijls NH, et al. Circadian and weekly variation and the influence of environmental variables in acute myocardial infarction. Neth Heart J. 2012; 20 (9):354-9.
2. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130 (25):e344-426.
3. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37 (3):267-315.
4. Kacprzak M, Kidawa M, Zielińska M. Fever in myocardial infarction: is it still common, is it still predictive?. Cardiol J. 2012;19 (4):369-73.
5. O'Gara PT, Kushner FG, Ascheim DD, et al. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127 (4):e362-425.
6. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC); Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33 (20):2569-619.
7. Storrow AB, Nowak RM, Diercks DB, et al. Absolute and relative changes (delta) in troponin I for early diagnosis of myocardial infarction: Results of a prospective multicenter trial. Clin Biochem. 2015;48 (4-5):260-7.
8. Storrow AB, Christenson RH, Nowak RM, et al. Diagnostic performance of cardiac troponin I for early rule-in and rule-out of acute myocardial infarction: Results of a prospective multicenter trial. Clin Biochem. 2015;48 (4-5):254-9.
9. Reichlin T, Irfan A, Twerenbold R, et al. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation. 2011; 12. 124(2):136-45.
10. Haaf P, Reichlin T, Corson N, et al. B-type natriuretic peptide in the early diagnosis and risk stratification of acute chest pain. Am J Med. 2011;124 (5):444-52.
11. Thygesen K, Mair J, Mueller C, et al. Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J. 2012; 33 (16):2001-6.
12. Cremer PC, Khalaf S, Agarwal S, et al. Myocardial perfusion imaging in emergency department patients with negative cardiac biomarkers: yield for detecting ischemia, short-term events, and impact of downstream revascularization on mortality. Circ Cardiovasc Imaging. 2014; 7 (6):912-9.