Atypical presentations and other challenges in the management of acute coronary syndrome in developing countries

Abstract

Background: Acute coronary syndrome (ACS) is a medical emergency and its management must be optimal in all patients. The existing guidelines such as the American College of Cardiology/American Heart Association and the European Society of Cardiology do not capture the peculiar challenges such as the nature of patients, non-availability of required facilities and clinical skills in the management of the spectrum of ACS in many hospitals in low-resource countries. Aim: The aim of this study is to report the challenges in the presentation and management of ACS in a developing country. Case Report: A 75-year-old male, diabetic and hypertensive of 5-year duration with poor drug adherence, presented with a 5-day history of epigastric pain radiating to the back and was managed for gastritis by a close relative who is a retired paramedic. He subsequently developed dyspnoea with profuse diaphoresis a day to presentation to the tertiary hospital. Examination on presentation revealed an elderly male in respiratory distress, pale with cold extremities, pulse 152 bpm and thready and blood pressure was unrecordable. Electrocardiogram (ECG) showed extensive anterior wall myocardial infarction (MI) complicated by ventricular tachycardia (VT). The cardiac troponin I was 27.2 ng/l and troponin T was 54 ng/l. Random blood glucose was 24 mmol/l. A diagnosis of ST elevation MI with VT in cardiogenic shock was made. The patient had oxygen, aspirin, clopidogrel, insulin and serial ECG monitoring but no facilities for cardioversion and the patient died on the same day. Conclusion: Management of ACS in developing countries has peculiar challenges such as atypical presentations, delayed presentation, paucity of facilities and delay in diagnosis and treatment. The hospitals should make ECG mandatory for adults presenting in the emergency rooms and improve on the existing facilities.