Death due to unrecognised myocardial infarction causing left ventricular rupture: can we improve the diagnostic rate?

To investigate the clinical presentations of ruptured myocardial infarction, where the initial diagnosis of myocardial infarction was missed, to enhance the diagnostic rate of primary care physicians.

We studied 67 cases of myocardial infarction, terminating with left ventricular rupture, between January 1988 and December 1996. The study was restricted to sudden death where, at coroner-directed autopsy, a ruptured myocardial infarction was determined as the cause of death. It was also restricted to patients who consulted a doctor within the two weeks prior to death. The report made to the coroner by attending police and the autopsy report was studied, and the requisite data were abstracted.

Half of our study group did not present with chest pain. Of the atypical presentations: 15/67 cases (22%) were from referred pain (neck, arm, abdomen or back), 12/ 67 patients presented with "flu-like illness" (18%), 4/67 cases had respiratory presentations (cough or shortness of breath) (6%) and 2/67 falls (3%). Of those with chest pain, 16/34 (47%) were diagnosed or referred and 2/15 infarcts with atypical or referred pain were diagnosed. None of those presenting with "flu like illness" or respiratory symptoms was diagnosed or referred.

Fifty per cent of our patients had "silent" myocardial infarcts. A large proportion of this group complained of a flu-like illness, which is currently not considered a presentation of this disease. Patients at higher risk of a myocardial infarct, should be treated with a high index of suspicion when unwell, especially when complaining of a flu-like illness. Pathologically, posterior and lateral infarcts accounted for over half the cases.