72 Yrs/M with Chest Pain

[JNUS]

Clinical Background

72 year old man presented with atypical chest pain lasting 2 hours
H/o Diabetes(+), Hypertension(+) no smoking
weight lose and symptom of prostatism for 1 year
COPD and osteoporosis history

Investigations

ECG: Left ventricular strain patern(ST segment depression and T inversion on d1,aVL,V4-5-6 )
troponin:negative
CK:41 IU/L CK-MB: 67 IU/L

whats your diagnosis?

[Ramri]

myocardial infarction

[flirt]

Acute coronary syndrome

[kniraz]

i don't think it is MI since there is ST depression

[flirt]

Kniraz said: " i don't think it is MI since there is ST depression"
MI is a differential diagnosis.
ST depression can cause NSTEMI (Non ST elevation MI)
So before you collect enough evidence to rule ouT MI you can't say just by seeing ST depression.

[kniraz]

Originally Posted by flirt

Kniraz said: " i don't think it is MI since there is ST depression"
MI is a differential diagnosis.
ST depression can cause NSTEMI (Non ST elevation MI)
So before you collect enough evidence to rule ouT MI you can't say just by seeing ST depression.

thanks for correcting me...

[JNUS]

Ck:41 Iu/l
Ck-mb: 67 Iu/l ??????

Ck-mb > Ck ??????

[Soul]

Normal value of CK-MB is 0-8 ng/ml (0-4% of total CK). I think CK-MB is 6.7 in this case.

Chest pain in an old man with H/O DM and HTN strongly suggest coronary artery disease. Normal CK, CK-MB values (though time is not mentioned) rule out myocardial infarction. Acute coronary syndrome could be an initial diagnosis, but normal cardiac enzyme rule out MI so it would be better to say Unstable angina...but this case doesn't look like so. It could be chronic stable angina (but history is not sufficient and pain should not last for 2 hr)

LV strain pattern and 'atypical' chest pain could be due to left ventricular hypertrophy, and this patient also has a H/O HTN. However, not much info about tall QRS complex etc etc.
Anway, I go for left ventricular hypertrophy. or chest pain under investigation (coz more investigation required to make a proper diagnosis )

[JNUS]

Originally Posted by Soul

Normal value of CK-MB is 0-8 ng/ml (0-4% of total CK). I think CK-MB is 6.7 in this case.

No soul, its 67.... here CK-MB > CK....

Hint : Search for the cases where CKMB is greater than CK....

[Soul]

So its not a typo error neither a lab error. Actually there are cases of AMI where CK was normal but CK-MB was highly elevated, but in this case troponin is also negative. Could it be due to early measurement of cardiac enzymes (2 hrs), coz neither CK nor troponin would be detected under 2 hours of presentation (if it is a case of AMI). I guess CK-MB having slightly lower molecular weight can be detected earlier than CK. But CK-MB value is too high which makes more confusion.

Is prostatism the culprit? TURP can lead to increase in CK-MB alone (some studies showed no rise in CK, but highly elevated level of CK-MB after TURP), but no H/O TURP in this case. I don't know whether prostatism alone can cause increase in CK-MB, not CK.

Sorry I couldn't figure out the Dx. Since CK-MB is high, MI can not be ruled out. I would repeat ECG and look for 'dongtai gaibian' and biomarker test and treat for Non-STEMI. If no changes in ECG and troponin after few hours, then MI could be ruled out and look for other causes.

Looking for the answer.