Chia Bing En Nazirah Hamzah Mohd Saifful Nizam Ismail


  1. Introduction: An acute coronary syndrome (ACS) can manifest with atypical presentations. Premature or inappropriate discharge can pose greater risk for major cardiac event specifically cardiac death.
  2. Case report: A middle aged gentleman presented to the emergency department with sudden onset of severe epigastric pain started in the afternoon. He was a high risk cardiac patient with history of COROS done twice, and recently thrombolysed twice within last 6 months. The current symptom caused a diagnostic dilemma as his previous cardiac event manifested as typical chest pain. Serial ECG showed RBBB with AF and no dynamic changes compared to baseline. Single test of cardiac enzymes taken less than 6 hours from onset of symptom were within normal range, but to our greater limitation no Troponin test available in our setting. Other investigation modalities done ruling out life threatening differentials were unremarkable. Referrals to primary teams were made and review by physician resulted with patient diagnosed as Peptic Ulcer Disease and discharged. Unfortunately he was brought in dead by the 12th hour post discharge. Post mortem reported as death due to cardiac event.
  3. Discussion & Conclusion: Chest and epigastric pain are common presentations in the emergency setting. The HEART pathway can be utilized for initial assessment of suspecting cardiac event patients presenting especially with atypical symptoms to rule in ACS. The other useful diagnostic risk stratification scoring including the GRACE and TIMI RS's relevant scores. It is important for early recognition of ACS and treated accordingly as ACS can be potentially life threatening.




acute coronary syndrome, atypical presentation, heart score

EMAS Meeting 2018 Abtracts