An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report

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Abstract

Background

Shoulder pain (SP) may originate from both musculoskeletal and visceral conditions. Physiotherapists (PT) may encounter patients with life-threatening pathologies that mimic musculoskeletal pain such as Acute Myocardial Infarction (AMI). A trained PT should be able to distinguish between signs and symptoms of musculoskeletal or visceral origin aimed at performing proper medical referral.

Case presentation

A 46-y-old male with acute SP lasting from a week was diagnosed with right painful musculoskeletal shoulder syndrome, in two successive examinations by the emergency department physicians. However, after having experienced a shift of the pain on the left side, the patient presented to a PT. The PT recognized the signs and symptoms of visceral pain and referred him to the general practitioner, which identified a cardiac disease. The final diagnosis was acute myocardial infarction.

Conclusion

This case report highlights the importance of a thorough patient screening examination, especially for patients treated in an outpatient setting, which allow distinguishing between signs and symptoms of musculoskeletal from visceral diseases.

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Most cited references 58

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2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).

Marco Roffi, Carlo Patrono, Jean-Philippe Collet … (2016)

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Third universal definition of myocardial infarction.

Markku Nieminen, Mihai Gheorghiade, Gerasimos Filippatos … (2012)

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Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials

(2013)

Summary Background The vascular and gastrointestinal effects of non-steroidal anti-inflammatory drugs (NSAIDs), including selective COX-2 inhibitors (coxibs) and traditional non-steroidal anti-inflammatory drugs (tNSAIDs), are not well characterised, particularly in patients at increased risk of vascular disease. We aimed to provide such information through meta-analyses of randomised trials. Methods We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 person-years) and 474 trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years). The main outcomes were major vascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death); major coronary events (non-fatal myocardial infarction or coronary death); stroke; mortality; heart failure; and upper gastrointestinal complications (perforation, obstruction, or bleed). Findings Major vascular events were increased by about a third by a coxib (rate ratio [RR] 1·37, 95% CI 1·14–1·66; p=0·0009) or diclofenac (1·41, 1·12–1·78; p=0·0036), chiefly due to an increase in major coronary events (coxibs 1·76, 1·31–2·37; p=0·0001; diclofenac 1·70, 1·19–2·41; p=0·0032). Ibuprofen also significantly increased major coronary events (2·22, 1·10–4·48; p=0·0253), but not major vascular events (1·44, 0·89–2·33). Compared with placebo, of 1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not significantly increase major vascular events (0·93, 0·69–1·27). Vascular death was increased significantly by coxibs (1·58, 99% CI 1·00–2·49; p=0·0103) and diclofenac (1·65, 0·95–2·85, p=0·0187), non-significantly by ibuprofen (1·90, 0·56–6·41; p=0·17), but not by naproxen (1·08, 0·48–2·47, p=0·80). The proportional effects on major vascular events were independent of baseline characteristics, including vascular risk. Heart failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs 1·81, 1·17–2·81, p=0·0070; diclofenac 1·89, 1·16–3·09, p=0·0106; ibuprofen 3·97, 2·22–7·10, p<0·0001; and naproxen 4·22, 2·71–6·56, p<0·0001). Interpretation The vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs, whereas high-dose naproxen is associated with less vascular risk than other NSAIDs. Although NSAIDs increase vascular and gastrointestinal risks, the size of these risks can be predicted, which could help guide clinical decision making. Funding UK Medical Research Council and British Heart Foundation.

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Author and article information

Contributors

Lorenzo Storari:

ORCID: https://orcid.org/0000-0003-4848-4262

ftstorari@gmail.com

Valerio Barbari:

ORCID: https://orcid.org/0000-0002-7990-7048

ft.valeriobarbari@gmail.com

Fabrizio Brindisino:

ORCID: https://orcid.org/0000-0001-8950-8203

fabrindi@gmail.com

Marco Testa:

ORCID: https://orcid.org/0000-0001-8643-7200

marco.testa@unige.it

Maselli Filippo:

ORCID: https://orcid.org/0000-0001-9683-9975

masellifilippo76@gmail.com

Journal

Journal ID (nlm-ta): Arch Physiother

Journal ID (iso-abbrev): Arch Physiother

Title: Archives of Physiotherapy

Publisher: BioMed Central (London )

ISSN (Electronic): 2057-0082

Publication date (Electronic): 15 February 2021

Publication date PMC-release: 15 February 2021

Publication date Collection: 2021

Volume: 11

Electronic Location Identifier: 5

Affiliations

[1 ]GRID grid.5606.5, ISNI 0000 0001 2151 3065, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), , University of Genova - Campus of Savona, ; Savona, Italy

[2 ]GRID grid.10373.36, ISNI 0000000122055422, Department of Medicine and Health Science “Vincenzo Tiberio”, , University of Molise c/o Cardarelli Hospital, ; C/da Tappino, Campobasso, Italy

Author information

Lorenzo Storari https://orcid.org/0000-0003-4848-4262

Valerio Barbari https://orcid.org/0000-0002-7990-7048

Fabrizio Brindisino https://orcid.org/0000-0001-8950-8203

Marco Testa https://orcid.org/0000-0001-8643-7200

Maselli Filippo https://orcid.org/0000-0001-9683-9975

Article

Publisher ID: 99

DOI: 10.1186/s40945-021-00099-x

PMC ID: 7883431

PubMed ID: 33583432

SO-VID: 6ea01eca-8969-424f-b1f5-227f14bc3f34

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 26 November 2020

Date accepted : 19 January 2021

Custom metadata

Keywords: anterior wall myocardial infarction,differential diagnosis,referral and consultation,shoulder pain,physiotherapy

Data availability:

Keywords: anterior wall myocardial infarction, differential diagnosis, referral and consultation, shoulder pain, physiotherapy

An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report

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Abstract

Background

Case presentation

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Most cited references 58

2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).

Third universal definition of myocardial infarction.

Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials

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