Atypical Presentation of Acute Myocardial Infarction in a Young Female with

No Cardiovascular Risk Factors

Abstract

Acute myocardial infarction (AMI) is frequently linked to traditional risk factors such smoking,
high blood pressure, and high cholesterol. However, unusual presentations in patients—
especially in young girls—who do not have these conventional risk markers might be difficult to
diagnose. This clinical vignette highlights the significance of taking AMI into consideration in
the differential diagnosis even in the absence of usual symptoms and risk profiles. It illustrates a
case of AMI in a 29-year-old female with no known cardiovascular risk factors.

Introduction

The majority of elderly persons with documented cardiovascular risk factors are affected by
acute myocardial infarction (AMI). Atypical appearances in young females without these risk
factors may cause a delay in diagnosis. This case demonstrates why, in atypical circumstances, it
is imperative to maintain a high index of suspicion for AMI, particularly in populations that are
not typically thought to be at high risk

Case Presentation

Patient Profile

 Age: 29 years
 Sex: Female
 Ethnicity: Caucasian
 Occupation: Schoolteacher
 Medical History: No significant past medical history, no known cardiovascular risk
factors (e.g., no hypertension, diabetes, hyperlipidemia, smoking history, or family
history of premature cardiovascular disease).
 Medications: None
 Social History: Socially active, moderate alcohol consumption, no history of substance
abuse.

Chief Complaint

The patient arrived to the emergency room (ED) after experiencing nausea, intermittent
epigastric discomfort, and a widespread weakness for the previous 24 hours. Lying down made
the agony worse, according to her description, which was a "burning" sensation that occasionally
spread to her back. She denied experiencing palpitations, dyspnea, or chest pain.
.

Initial Assessment

 Vital Signs:
o Blood Pressure: 120/75 mmHg
o Heart Rate: 88 beats per minute
o Respiratory Rate: 16 breaths per minute
o Temperature: 98.6°F (37°C)
o Oxygen Saturation: 99% on room air
 Physical Examination:
o General: Alert, oriented, and in no apparent distress.
o Cardiovascular: Normal heart sounds, no murmurs, rubs, or gallops. No jugular
venous distention.
o Respiratory: Clear to auscultation bilaterally, no wheezing, rales, or rhonchi.
o Abdomen: Soft, non-tender, non-distended. No rebound or guarding. Normal
bowel sounds.
o Extremities: No edema, pulses equal and strong bilaterally.

Differential Diagnosis

Given the atypical presentation, the initial differential diagnosis included:

 Gastroesophageal reflux disease (GERD)

 Peptic ulcer disease
 Gallbladder disease (cholecystitis)
 Pancreatitis
 Musculoskeletal pain
 Atypical acute coronary syndrome (ACS)

Investigations

1. Electrocardiogram (ECG):
o Initial ECG was unremarkable, with no ST-segment elevation, depression, or
significant T-wave changes.
2. Laboratory Tests:
o Complete Blood Count (CBC): Within normal limits.
o Comprehensive Metabolic Panel (CMP): Normal electrolytes, liver function, and
renal function.
o Cardiac Biomarkers:
 Initial Troponin I: 0.4 ng/mL (slightly elevated; normal range <0.04
ng/mL)
 Repeat Troponin I after 3 hours: 2.3 ng/mL (significantly elevated)
3. Imaging:
o Chest X-ray: No acute cardiopulmonary abnormalities.
 o Echocardiogram: Mild hypokinesis of the inferior wall, left ventricular ejection
fraction (LVEF) estimated at 50%.

Diagnosis

Despite the lack of typical chest pain and risk factors, the patient’s elevated troponin levels,
combined with echocardiographic findings, raised suspicion for an acute coronary syndrome.
The diagnosis of non-ST elevation myocardial infarction (NSTEMI) was made.

Management

 Initial Medical Management:

o Antiplatelet Therapy: Aspirin 325 mg chewable was administered immediately,
followed by clopidogrel 75 mg daily.
o Anticoagulation: Enoxaparin 1 mg/kg subcutaneously every 12 hours.
o Nitroglycerin: Sublingual nitroglycerin was given for ongoing epigastric
discomfort, with subsequent pain relief.
o Beta-blocker: Metoprolol tartrate 25 mg twice daily.
o Statin: Atorvastatin 80 mg daily was initiated.
 Cardiology Consultation: The patient was referred for an urgent coronary angiography,
which revealed a 70% stenosis in the left anterior descending (LAD) artery, successfully
treated with percutaneous coronary intervention (PCI).
 Post-Intervention Care:
o Dual Antiplatelet Therapy (DAPT): Continued with aspirin and clopidogrel for
at least 12 months.
o Lifestyle Modification: The patient was counseled on diet, exercise, and stress
management. Despite the absence of traditional risk factors, lifestyle optimization
was emphasized.
o Cardiac Rehabilitation: Enrolled in a structured cardiac rehabilitation program.

Discussion

This case underscores the importance of considering acute myocardial infarction (AMI) in young
females, even in the absence of traditional cardiovascular risk factors and typical chest pain.
Atypical presentations, such as epigastric pain, can delay diagnosis and treatment. This patient’s
case highlights the need for thorough evaluation, including the use of cardiac biomarkers and
imaging, even when initial clinical suspicion is low.

Learning Points

1. Atypical Symptoms: AMI can present with atypical symptoms, particularly in young
females, which can lead to diagnostic delays.
2. Importance of Cardiac Biomarkers: Elevated troponin levels are critical for diagnosing
myocardial infarction, even when the ECG is unremarkable.
 3. Early Intervention: Prompt recognition and intervention, including PCI, are essential to
improving outcomes in patients with acute coronary syndromes.
4. Patient Education and Follow-up: Ongoing education and lifestyle modification are
crucial, even for patients without traditional risk factors, to prevent recurrence.

Conclusion

This clinical vignette demonstrates the importance of maintaining a high index of suspicion for
acute coronary syndromes in patients with atypical presentations and the absence of conventional
risk factors. Early identification and management of AMI, including the use of PCI, can
significantly improve patient outcomes.

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