Massive Myocardial Infarction Presenting With Abdominal Pain and Non-Specific ECG Findings: A Fatal Case Report
Abstract
Serife Bilgehan Arici* and Ozan Durmaz
Background Acute myocardial infarction (AMI) typically presents with chest pain; however, atypical presentations may lead to delayed recognition and fatal outcomes. Abdominal pain accompanied by a normal initial electrocardiogram (ECG) can mask underlying myocardial infarction, particularly in younger patients with cardiovascular risk factors.
Case Presentation A 40-year-old male heavy smoker (two packs per day) initially presented to a general practitioner with severe abdominal pain. Physical examination revealed a soft abdomen with mild epigastric tenderness without guarding or rebound tenderness. No chest pain or other classic cardiac symptoms were reported. Proton pump inhibitors (PPI) and analgesics were prescribed for presumed gastritis. Initial ECG showed no specific abnormalities.
Approximately 24 hours later, the patient developed recurrent abdominal pain accompanied by chest pain and acute dyspnea lasting approximately 30 minutes and called emergency medical services (112). Upon ambulance arrival, oxygen saturation was 82%, blood pressure 80/50 mmHg, and heart rate 136 beats per minute.
The patient appeared pale, diaphoretic, and tachypneic. Cardiac auscultation revealed tachycardia with a regular rhythm and no audible murmurs. Pulmonary examination demonstrated decreased breath sounds at the left lung base with mild bibasilar crackles. Chest radiography revealed left-sided pleural effusion without other acute findings.
Shortly after hospital arrival, the patient experienced sudden cardiovascular collapse. Immediate cardiopulmonary resuscitation (CPR) was initiated with continuous chest compressions and repeated administration of intravenous epinephrine according to advanced life support protocols. Despite resuscitative efforts, return of spontaneous circulation could not be achieved.
Laboratory testing obtained shortly before death demonstrated markedly elevated cardiac biomarkers, including cardiac troponin levels above the institutional cut-off value (0.9 ng/L) and CK-MB levels of 521 U/L, approximately 15–30 times above the upper reference limit, consistent with massive myocardial infarction.
Conclusion This case highlights the diagnostic challenge posed by atypical presentations of myocardial infarction. Clinicians should maintain a high index of suspicion for cardiac causes in patients presenting with unexplained abdominal pain, even when the initial ECG is normal. Early recognition of atypical symptoms and prompt diagnostic evaluation are critical to prevent fatal outcomes.