The Diagnosis and Treatment of Acute Coronary Heart Disease Without Objective Findings

Abstract

There are patients with acute coronary heart disease who have no objective evidence of myocardial infarction by electrocardiogram or laboratory tests, in fact who have no objective evidence of any cardiac change whatsoever. In such patients, the clinician, purely on a history as he obtains it, is faced with the necessity of making a diagnosis which carries with it at least initially, potential consequences of grave significance. The complexity of such a serious diagnosis is compounded by the fact that the history is usually atypical. It is such atypical histories that frequently lead to a reassuring pat on the back with some vague remark about “muscle pain.” It is also such histories that occasionally end with sudden death. Given a patient, middle aged or beyond, with a vague chest discomfort that has no diagnostically helpful relationship, and in whom there are no objective evidences of heart disease, one is faced in the first instance with the necessity of excluding acute coronary heart disease. In the usual situation any other diagnostic possibility is such that it can await the fullest possible consideration of the cardiac status. If an electrocardiogram can be recorded during the course of the pain, transient ischemic changes will occasionally be diagnostically helpful. If such changes are not observed, it is my belief that any suspicion of an acute coronary episode should justify a tentative diagnosis of acute coronary heart disease. The index of suspicion should be especially high in any patient middle aged or above who spontaneously develops chest or upper abdominal distress of any sort that is not clearly or easily identifiable as due to some non-cardiac cause. In such a situation one can do little more than conclude that it is impossible to eliminate acute coronary heart disease as a diagnosis. Therefore, it is impossible to exclude the possibility of sudden death, or of the development of a major myocardial infarction. Since such serious complications cannot be discounted, management must be directed accordingly. Even a known history of peptic ulcer or x-ray evidence of gallstones should be ignored initially unless the clinical picture can be surely related to these conditions. There should be no diagnostic difficulty when a patient presents himself with a history that is fairly typical of the pain of acute coronary heart disease but without objective findings. This includes patients with the onset of classical angina of effort, or the acute worsening of pre-existing angina. The typical history should suffice for a tentative diagnosis of acute coronary heart disease. The patient with an atypical history, however, may present himself with little more than mild to moderate substernal discomfort that comes and goes spontaneously and is often associated with belching and indefinite upper abdominal distress, in other words “indigestion.” The discomfort may extend into the neck. If the