Hrev_master [page 48] [Emergency Care Journal 2025; 21:13362] Emergency Care Journal 2025 volume 21:13362 Abstract An 86-year-old man presented to the emergency department with abdominal pain in the left iliac fossa and constipation in the previous three days. Laboratory tests revealed an increase in C- reactive protein levels (22.37 mg/dL), white blood cell count (12.38x109/L), neutrophil count (10.07x109/L), and hyperglycemia (237 mg/dL). An abdominal contrast-enhanced computed tomog- raphy scan ruled out acute abdominal pathological findings but showed a marked hypoperfusion of the mid-apical anterior wall and the apex of the left ventricle. A subsequent electrocardiogram revealed an excessive ST elevation (>5 mm) and a negative QRS complex in precordial leads (from V1 to V6). Serial assays of high- sensitivity troponin I showed a plateau phase (from 15696.4 to 15479.3 ng/L). Echocardiography revealed a left ventricle dilated and severely hypokinetic (ejection fraction of approximately 15- 20%). A diagnosis of subacute myocardial infarction with severe dysfunction of the left ventricle was therefore made. Introduction A contrast-enhanced computed tomography (CT) scan is not typically included in the evaluation of myocardial infarction.1 However, many patients may present with atypical symptoms, leading them to undergo an emergency contrast-enhanced CT scan to rule out other suspected acute conditions. In some cases, this scan may ultimately reveal a myocardial infarction.2 We report a case of a subacute myocardial infarction detected by an abdominal contrast-enhanced CT scan. Case Report An 86-year-old man presented to the emergency department with abdominal pain in the left iliac fossa and constipation in the previous three days. His medical history included cholecystectomy for lithiasis, radical prostatectomy for prostate cancer, dual-cham- ber pacemaker implantation for second-degree atrioventricular block, drug-eluting stent implantation in the left anterior descend- ing artery for acute myocardial infarction, chronic ischemic heart disease, hypertension, and type 2 diabetes mellitus. He was under treatment with low-dose aspirin, irbesartan, hydrochlorothiazide, bisoprolol, pantoprazole, metformin, silodosin, and amlodipine. On physical examination, his vital signs were normal, and his abdomen was tender in the left iliac fossa with no signs of periton- ism. Laboratory tests revealed a marked increase in C-reactive pro- tein levels (22.37 mg/dL), a modest increase in white blood cell count (12.38x109/L) and neutrophil count (10.07x109/L) and hyperglycemia (237 mg/dL). An abdominal contrast-enhanced CT scan ruled out acute pathological findings in the abdominal cavity but caught a few slices of the heart showing a marked hypoperfu- sion of the mid-apical anterior wall and the apex of the left ventri- cle (Figure 1); the CT scan showed no thrombus in the left ventric- ular lumen. A subsequent 12-lead electrocardiogram (ECG) revealed spontaneous atrial rhythm followed by ventricular paced rhythm with an excessive ST elevation (>5 mm) and a negative Correspondence: Massimo Barakat, Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, via Pietro Albertoni 15, 40138 Bologna, Italy. Tel.: +39.0512144327 E-mail: massimo.barakat@gmail.com Key words: myocardial infarction; computed tomography; electro- cardiogram; heart. Contributions: MB conceptualized and wrote the manuscript; EB reviewed the electrocardiogram and the clinical-laboratory data relating to the cardiological history of the patient and helped in writ- ing the manuscript; LM visited the patient in the emergency depart- ment and collected his clinical-laboratory data and his electrocardio- gram; FG helped in drafting the report of the abdominal computed tomography scan; SGN drafted the report of the abdominal comput- ed tomography scan. All authors approved the final version of the manuscript. Conflicts of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: since this is a descriptive case report and data were collected without patient identifiers, ethics approval was not necessary according to our hospital’s Institutional Review Board guidelines. Informed consent: the patient provided consent for access to medical records at the time of admission. Availability of data and materials: all data and materials are included in this published article. Received: 9 November 2024. Accepted: 9 December 2024. Early view: 22 January 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13362 doi:10.4081/ecj.2025.13362 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. A myocardial infarction detected in an unusual way Massimo Barakat,1 Enrico Bertagnin,2 Lorenzo Mulazzani,3 Francesco Galuppi,1 Sanda Giovanna Nizzardo1 1Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero- Universitaria di Bologna; 2Division of Provincial Cardiology, Cardiothoracic Vascular Department, Azienda Unità Sanitaria Locale di Ferrara; 3Emergency Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy QRS complex in precordial leads (from V1 to V6) (Figure 2). These alterations were not compatible with repolarization alter- ations secondary to ventricular pacing, but they were strongly sus- picious for ischemia. Serial assays of high-sensitivity troponin I showed a plateau phase (levels ranged from 15696.4 to 15479.3 ng/L; normal values < 19.8 ng/L). B-type natriuretic peptide levels were 678 pg/mL (normal values <100 pg/mL). Echocardiography revealed a left ventricle dilated, hypokinesia of the anterior and anterolateral wall of the left ventricle, and akinesia of mid anteroseptal and apical septal segments of the left ventricle (ejec- tion fraction of approximately 15-20%). Based on all of these find- ings, a diagnosis of subacute myocardial infarction with severe dysfunction of the left ventricle was made. A dual antiplatelet ther- apy (aspirin and clopidogrel) was undertaken because of patient frailty and subacute presentation of myocardial infarction. A few days later, the patient presented with melena and severe anemia (hemoglobin 5.7 g/dL); dual antiplatelet therapy was suspended, and the patient underwent esophagogastroduodenoscopy, which revealed some ulcerative lesions in the gastric body and antrum. After some transfusions of red cell concentrates, aspirin was resumed. Clinical conditions improved, and the patient was finally discharged from the hospital with home therapy (low-dose aspirin, folic acid, atorvastatin, bisoprolol, furosemide, pantoprazole, met- formin, dapagliflozin, canrenone, and silodosin). Case Report [Emergency Care Journal 2025; 21:13362] [page 49] Figure 1. Axial (A), coronal (B), and sagittal (C) contrast-enhanced computed tomography scan of the abdomen showing a marked hypop- erfusion of the mid-apical anterior wall and the apex of the left ventricle (red arrows). Figure 2. 12-lead electrocardiogram showing spontaneous atrial rhythm followed by ventricular paced rhythm with an excessive ST ele- vation (>5 mm) and a negative QRS complex in precordial leads (from V1 to V6). A notch in the ascending limb of the S wave in lead V3, and less evident in the ascending limb of the S wave in lead V4, is also present (the so-called “Cabrera’s sign”). These alterations were not compatible with repolarization alterations secondary to ventricular pacing, but they were strongly suspicious for ischemia. Discussion and Conclusions The prevalence of myocardial infarctions presenting with atyp- ical symptoms is high (nearly 34%).3 The atypical symptoms tend to occur more commonly among older, female, diabetic (possibly due to autonomic neuropathy), hypertensive, and with prior heart failure patients.4 Atypical presentations frequently cause delays in seeking care, suspecting or diagnosing by the treating physician, resulting in a poor prognosis.5 One of the most common atypical presentations of myocardial infarction is gastrointestinal discomfort (21.43%).4 As a result, some patients undergo an emergency CT scan of the abdomen because of suspected abdominal pathologies.6 Abdominal CT scans frequently cover the caudal parts of the heart, allowing the evaluation of myocardial contrast attenuation and possibly sus- pecting ischemia.7 The pattern of coronary perfusion is centripetal, with the subepicardium of the left ventricle better perfused and thus more resistant to ischemia than the subendocardium. Perfusion abnormalities, therefore, usually manifest first and most profoundly in the subendocardium. The subepicardium is usually less affected by perfusion abnormalities, but transmural ischemia can also occur. Ischemic defects follow specific coronary territo- ries.6 As a result, radiologists could help shorten delays to myocar- dial infarction diagnosis in some cases by taking a quick look at myocardial contrast attenuation. However, a recent retrospective single-center study assessed that radiologists regularly miss myocardial hypoperfusion during the evaluation of abdominal CT scans, probably because they do not think about the eventuality of myocardial infarction.7 Nevertheless, it is important to underline that radiological visualization of myocardial hypoperfusion alone does not typically reveal the onset, apart from cases where calcifications or fatty atro- phy of the myocardium are present: medical history, ECG, echocardiography, and laboratory parameters can therefore help to decide whether an acute or a chronic situation is present or not.7 In conclusion, emergency radiologists should look at myocar- dial contrast attenuation during the evaluation of abdominal CT scans, especially in those patients who present to the emergency department with gastrointestinal discomfort, cardiovascular risk factors, and no pathological findings in the abdominal cavity on CT images. Emergency physicians should think about atypical manifestations of myocardial infarction in those patients who pre- sent to the emergency department with gastrointestinal discomfort and cardiovascular risk factors, especially if CT scan rules out pathological findings in the abdominal cavity. References 1. Thygesen K, Alpert JS, Jaffe AS, et al. Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). Circulation 2018;138:e618-51. 2. Gosalia A, Haramati LB, Sheth MP, Spindola-Franco H. CT detection of acute myocardial infarction. AJR Am J Roentgenol 2004;182:1563-6. 3. Breining A, Negers A, Mora L, et al. Determinants of clinical presentation on outcomes in older patients with myocardial infarction. Geriatr Gerontol Int 2018;18:1591-6. 4. Khan IA, Karim HMR, Panda CK, et al. Atypical presentations of myocardial infarction: a systematic review of case reports. Cureus 2023;15:e35492. 5. Lee JW, Moon JS, Kang DR, et al. Clinical impact of atypical chest pain and diabetes mellitus in patients with acute myocar- dial infarction from prospective KAMIR-NIH Registry. J Clin Med 2020;9:505. 6. Shriki JE, Shinbane J, Lee C, et al. Incidental myocardial infarct on conventional nongated CT: a review of the spectrum of findings with gated CT and cardiac MRI correlation. AJR Am J Roentgenol 2012;198:496-504. 7. Talakić E, Schöllnast H, Kaufmann-Bühler AK, et al. The "car- diac neglect": a gentle reminder to radiologists interpreting contrast-enhanced abdominal MDCT. Front Cardiovasc Med 2023;10:1147166. Case Report [page 50] [Emergency Care Journal 2025; 21:13362]