Case Report

Headache angina Abstract

The initial recognition of acute myocardial infarction at

the time of the emergency department (ED) visit may be difficult in the absence of typical presentations such as chest pain, diaphoresis, and radiation tenderness. Headache angina, although reported in several instances in the past with variable patient outcomes, is still an uncommon phenomenon in patients with acute myocardial infarction. We report a patient with Inferior myocardial infarction who presented to the ED with a complaint of Severe headache and subsequent cardiogenic shock secondary to ventricular fibrillation.

“Time is muscle” is the rule of thumb in the emergency department (ED) regarding subsequent ventricular arrhyth- mias from acute myocardial infarctions. The initial recognition of acute myocardial infarction at the time of

the ED visit may be difficult in the absence of typical presentations such as chest pain, diaphoresis, and radiation tenderness. Headache angina, although reported in a few instances in the past with variable patient outcomes, is still an uncommon phenomenon in patients with acute myocar- dial infarction. We report a patient with inferior myocardial infarction who presented to the ED with a complaint of severe headache and subsequent cardiogenic shock second- ary to ventricular fibrillation.

An 81-year-old female Taiwanese presented to the ED department with the “most severe headache of her life” for several hours. She reported intermittent dizziness and headache for about a week without remarkable exacerbating or alleviating factors. Her headache worsened, and accom- panying symptoms of dizziness, diaphoresis, and nausea appeared on the morning of her ED visit. She was afebrile, with a blood pressure of 150/92 mm Hg, pulse rate of 58 beat/min, and a respiratory rate of 18 beat/min upon her ED visit. The patient has a history of hypertension and gouty arthritis under medical management.

Fig. 1 Return to sinus rhythm with ST elevation of II, III, and aVF after cardiopulmonary cerebrovascular resuscitation and defribillation.

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387.e2 Case Report

Loss of consciousness was noted 10 minutes after her initial triage. The electrocardiogram monitor depicted a ventricular fibrillation morphology. The patient was imme- diately defibrillated with monophasic 360 J, upon which she regained consciousness and a stabilized sinus rhythm. Moments later, ventricular fibrillation was noted again, this time requiring 2 defibrillations at 360 J each to restabilize (Fig. 1). A brain computed tomography examination showed unremarkable findings for hemorrhage. cardiology consult for an echocardiography revealed basal inferior wall akinesis with a left ventricular ejection fraction greater than 55% and a right ventricular ejection fraction of 22%. Primary percutaneous intervention was arranged and later revealed a 99% stenosis of the proximal right Circumflex artery. The culprit lesion was then dilated and stented. The remainder of her 1-week hospital stay was uncomplicated without further chest pain or headache.

Acute myocardial infarction must be recognized and managed as early as possible to salvage ischemic myocar- dium. Fortunately many patients display typical chest pain and its associated symptoms at the ED. Atypical presenta- tions elude ED physicians and thus the importance of raising its awareness. Although reported in previous literatures, myocardial infarction symptoms manifesting primarily as severe headache are still uncommon [1-5]. The variable mortality outcomes among those reported exemplify the importance of early recognition and management. Unlike the study by Culic et al [6], which attempted to describe an association between the occurrence of presenting symptoms and site of infarction, our patient did not have anterior infarction, which more commonly manifests the symptom of headache. However, our patient had the near total right circumflex artery occlusion similar to those that Famularo et al [2] described in his studies. Furthermore, this case was compatible with the recommendation of Amendo et al [7], who suggested the consideration of myocardial infarction in elderly patients who present with acute severe headache. The role of brain Computed tomography imaging is important to rule out the possibility of subarachnoid hemorrhage in patients with severe headache and differentiating subarach- noid hemorrhage-related arrhythmias, which are relatively common and potentially fatal [8].

The mechanism of headache angina is still unclear. It is unlikely that the headache can be attributed to only 1 mechanism. The referral of angina pain to converge on the central pathway of the afferent autonomic fibers is advocated by many authors [9]. Possibilities related to the decrease in cerebral perfusion and increase in intracranial pressures were also suggested in literature [10 11]. The clinical relationship to these mechanisms still remains to be studied.

Acute myocardial infarction is potentially fatal; early identification and intervention by emergency physicians can decrease patient morbidity and mortality. Atypical presenta- tions continue to be a challenge for ED physicians. However, with increasing awareness toward elderly patients with cardiovascular event risk factors, ED physicians will be able to combat the various atypical presentations of acute myocardial infarction.

Warren W. Wang MD Emergency Medicine Department Chang Gung Memorial Hospital

Lin-Kou, Taiwan ROC E-mail address: [email protected]

Chien-Sheng Lin MD Department of Emergency & Critical Care Medicine Cheng Hsin Rehabilitation Medical Center

Tian-Mu, Taiwan ROC

doi:10.1016/j.ajem.2007.07.029

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