ChiroACCESS Article



Recognition of Myocardial Infarction in Chiropractic Practice



This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Dwain M. Daniel, D.C.

  

ChiroACCESS



Published on

September 28, 2011

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There is an almost certain eventuality that on several occasions during your practice career a patient with an undiagnosed life threatening condition will present in your office [1].  To better prepare you for these events ChiroACCESS will be publishing a short series of papers on myocardial infarction, deep vein thrombosis, stroke, abdominal aortic aneurysm and subdural hematoma.  We will provide an evidence-based overview of the risk factors and signs and symptoms of these commonly encountered life threatening conditions.  This information should refresh your memory and help you recognize these conditions when they appear. 

Be prepared when one of these patients comes to your office!

Recognition of Myocardial Infarction in Chiropractic Practice



Background:  Whether in general practice or emergency room settings myocardial infarction (MI) is at the top or near the top of lists for missed or delayed diagnoses [2-4].  This fact alone should emphasize that presentations of MI are not necessarily easy to recognize and do not always manifest themselves as a “Hollywood heart attack”.  Becoming more aware of the different presentations of MI could help you recognize the possibility of MI in your patient and possibly save their life.   

About ½ of patients who suffer an acute MI die before they reach a hospital [5].   The time from onset of symptoms to arrival at the hospital has been examined in several studies [5-7] .  In one cross sectional study of 256 individuals over 50% delayed 6 hours or more from onset of symptoms to hospital presentation.  In a role reversal, women in this study delayed an average of 9.5 hours compared to an average delay of 6 hours for men [6].  Considering use of thrombolytic drugs during the first 3 hours is critical to minimize damage to the heart, the consequences of delay are obvious [8].

Patient presentation: 
 The reasons for delays are in part explained by the varying symptoms patients experience with MI, particularly the difference in symptoms experienced by men and women.   King et al reported when individuals had symptoms similar to what they would expect from a MI approximately 55% presented at the hospital in less than 1 hour after onset of symptoms.  Almost 65% of those that did not experience expected symptoms took 6 to 24 hours to present at the hospital [5].  Table 1 represents the list of symptoms reported by patients in the King study mentioned above.  Some of the more interesting findings were that right arm pain was almost as prevalent as left arm pain and men and women differed significantly in the location of pain.  Additionally men reported indigestion twice as often as women. 

Table 1
Symptoms of MI by gender


Symptom

Women

Men

Pain severity

6.81

7.58

Pain location

%

%

  Center of chest

56.7

90.0*

  Left arm

50.0

46.7

  Right shoulder

53.1

13.3*

  Right arm

40.0

36.7

  Center of back

40.0

36.7

Pain Descriptor

%

%

  Discomfort

76.7

90.0

  Pain

66.7

73.3

  Pressure

63.0

56.7

  Dull ache

50.0

60.0

  Tightness, heaviness, 
  pressing, constricting

36.7-50.0

43.3-63.3

Other symptoms

%

%

  General weakness

60.0

66.7

  Fatigue

60.0

46.7

  Diaphoresis

53.3

63.3

  Shortness of breath

46.7

50.0

  Nausea

43.3

50.0

  Lightheadedness

36.7

36.7

  Belching

30.0

36.7

  Indigestion

26.7

50.0 *


* Statistically significant difference

One of the more surprising deviations from what most consider a “normal” presentation of MI is the intensity of pain.  A recent study of 2904 patients reported that approximately ½ classified their pain as “low intensity” [9].  As the reader can see the varying symptoms of MI can easily lead to a missed or delayed diagnosis.   

Physical findings: 
According to the American Family Physician physical findings are often normal.  However the physician should check for :
The presence of any of these findings is considered significant [10].
 
Risk factors:  Many risk factors for myocardial infarction have been identified.  Table 2 identifies the most common [11]. 

Table 2


Reprinted with permission


Conclusion:  Chances are that at least 1 patient experiencing a myocardial infarction will present in your office sometime during your career.  Being aware of the variety of symptoms that can occur with a MI will improve your chances of identifying a patient if they have the misfortune of experiencing a MI.  Recognition on your part could ultimately be a “matter of life and death”.
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References

1.   

Daniel DM, Ndetan H, Rupert R, Martinez D: Recognition of Undiagnosed Life Threatening Conditions in Chiropractic Practice: A Randomized Survey. 2011; Toronto. 105.



2.   

McDonald C, Hernandez M, Gofman Y, Suchecki S, Schreier W: The five most common misdiagnoses: a meta-analysis of autopsy and malpractice data. Internet J Fam Pract 2009, 7.



3.   

Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA et al.: Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006, 145: 488-496.



4.   

Phillips RL, Jr., Bartholomew LA, Dovey SM, Fryer GE, Jr., Miyoshi TJ, Green LA: Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care 2004, 13: 121-126.



5.   

King KB, McGuire MA: Symptom presentation and time to seek care in women and men with acute myocardial infarction. Heart Lung 2007, 36: 235-243.



6.   

DeVon HA, Hogan N, Ochs AL, Shapiro M: Time to treatment for acute coronary syndromes: the cost of indecision. J Cardiovasc Nurs 2010, 25: 106-114.



7.   

Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K et al.: Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council. Circulation 2006, 114: 168-182.



8.   

Giugliano RP, Braunwald E: Selecting the best reperfusion strategy in ST-elevation myocardial infarction: it's all a matter of time. Circulation 2003, 108: 2828-2830.



9.   

Teoh M, Lalondrelle S, Roughton M, Grocott-Mason R, Dubrey SW: Acute coronary syndromes and their presentation in Asian and Caucasian patients in Britain. Heart 2007, 93: 183-188.



10.   

Achar SA, Kundu S, Norcross WA: Diagnosis of acute coronary syndrome. Am Fam Physician 2005, 72: 119-126.



11.   

Anand SS, Islam S, Rosengren A, Franzosi MG, Steyn K, Yusufali AH et al.: Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. Eur Heart J 2008, 29: 932-940.