Interventional Cardiologist Overlook Medical Center, United States
Introduction: Myocardial infarction in patients less than 45 years of age is a rare occurrence. In fact, the ASCVD Risk Calculator only provides optimal risk estimates for individuals 40 to 79 years of age. This case highlights the importance of including myocardial infarction as a top differential, regardless of age and risk factors. It is also important to remember that the patient with an impending sense of doom might be suffering from an acute MI.
Description: We present a case of a 39-year-old-Asian male with a past medical history of hyperlipidemia and prediabetes who presented to the Emergency Department for chest pain. The patient was taking out the garbage when he developed substernal chest pain, described as a pressure-like sensation. There were no other associated symptoms except for an impending sense of doom. Furthermore, there was no prior history of chest pain. He did not take any medications and exercised daily. He denied smoking, alcohol, illicit drug use and was unsure of his family history. On arrival, his blood pressure was 137/94 mmHg, and heart rate was 77 bpm. He was saturating 100% on room air. Physical examination revealed a non-obese male who appeared anxious. Initial troponin was 22 ng/L, and EKG showed NSR, LVH, and T wave inversions. CMP and CBC were within normal limits. The lipid panel revealed a total cholesterol of 205 mg/dL, with an LDL of 154 and HDL of 39. Triglycerides were 59 mg/dL. Lipoprotein (A) was 13 nmol/L. HbA1c was 6.0. While in the ED, the patient developed another episode of chest pain. Repeat troponin was 465 ng/L, and EKG revealed ST elevations in V1-V3, prompting activation of the cardiac catheterization lab. The patient was found to have a thrombotic occlusion of the LAD and underwent mechanical thrombectomy. Two drug-eluting stents were placed. He was started on Ticagrelor, Aspirin, and a high-intensity statin. ECHO showed LVEF of 40-45%, and he was started on GDMT.
Discussion: Although our patient had a history of prediabetes and hyperlipidemia, he was an active, non-obese young male who didn’t smoke or drink alcohol. Outside of chest pain, the patient’s only other symptom was an impending sense of doom. Although rare, an impending sense of doom should be remembered as a symptom of myocardial infarction, even in a patient with low-risk factors.
