Acute coronary syndrome (ACS) typically presents with a chest pain. We present a case in which a patient with high blood pressure presented with only headache and cause diagnostic dilemma.
63 years old Malay lady doctor with underlying history of hypertension and left mastectomy for breast carcinoma presented with sudden onset of headache and lethargy in the morning. She was on tablet Amlodepine 10mg daily and took etoricoxib 90 mg but headache persisted. Upon arrival the blood pressure was 216/90 mmHg, heart rate 101 per minute and temperature 37.6 degrees Celcius while the pain score was 5/10. Patient was treated as hypertensive urgency and given captopril 25 mg and additional tramadol 50 mg in view of persisting headache and monitored in observation ward. There was no chest pain. 1 hour later, upon reassessment patient claimed worsening of headache. Fundoscopy showed no papiloedema.There was no obvious neurological deficit and ECG showed ST elevation with q wave in lead III and depression in leads I and AVL. Then, patient informed developing severe neck pain. CT Brain was done to rule out subarachnoid haemorrhage. Patient was also uptriaged to resuscitation zone with troponin was taken. Repeat ECG showed evolving changes with Q wave at leads III, AVF and T inversion over II and AVF. Troponin level was raised at 0.256. The updated diagnosis was hypertensive emergency with NSTEMI. Patient was started IV infusion of GTN and was given T.aspirin 300 mg stat. Patient was further given enoxaparine and fondaparinox and admitted to the high dependency ward.
DISCUSSION & CONCLUSION
This is a case of hypertensive emergency affecting the myocardium but presenting atypically with high blood pressure and headache. Ensure ECG is always done especially for elderly patients despite no classic presentation of acute coronary syndrome. CT SCAN is essential to rule out intracranial event.