Misdiagnosis of Acute Myocardial Infarction: A Systematic Review of the Literature

Abstract

Despite the availability of tests to diagnose acute myocardial infarction (AMI), cases are still missed. We systematic reviewed the literature to determine how missed AMI has been defined, the reported rates of misdiagnosed AMI, the outcomes patients with misdiagnosed AMI have, what diagnosis was initially suspected in missed AMI cases, and what factors are associated with misdiagnosed AMI. We searched MEDLINE and EMBASE in September 2020 for studies that evaluated missed AMI. Data was extracted from studies that met the inclusion criteria and the results were narratively synthesized. A total of 15 studies were included in this review. The number of patients with missed AMI in individual studies ranged from 64 to 4,707.There was no consistently used definition for misdiagnosed AMI but most studies reported rates of approximately 1-2%. Compared to AMI that was recognized, one study found no difference in mortality for misdiagnosed AMI at 30 days and 1 year. The common initial misdiagnoses that subsequently had AMI were ischemic heart disease, non-specific chest pain, gastrointestinal disease, musculoskeletal pain and arrhythmias. Reasons for missed AMI include incorrect electrocardiogram interpretation and failure to order appropriate diagnostic tests. Hospitals in rural areas and those with a low proportion of classical chest pain patients that turned out to have AMI were at greater risk of missed AMI. Misdiagnosed AMI is an unfortunate part of everyday clinical practice and better training in electrocardiogram interpretation and education about atypical presentations of AMI may reduce the number of misdiagnosed AMI.

Recognising acute coronary syndrome

“…Classically, ACS presents as a sense of pressure radiating across the chest and down the left arm. However, it is less known that ACS can also present as dyspnoea, isolated jaw or arm pain, bilateral arm pain and back pain, or nausea and vomiting without any pain 6789. This can lead both patients and physicians to fail to recognise ACS.…”

“…This can lead both patients and physicians to fail to recognise ACS. Misinterpretation of an ECG and overreliance on a normal ECG have also been reported as causes of misdiagnosis by physicians 8. Among patients undergoing emergency evaluation, up to a third of ACS cases are misclassified during initial triage; fortunately, this drops to ~1% after full clinical assessment and observation (box 1).…”

“…Among patients undergoing emergency evaluation, up to a third of ACS cases are misclassified during initial triage; fortunately, this drops to ~1% after full clinical assessment and observation (box 1). 789 These initially missed cases are often detected as a result of changes in ECG results or troponin concentration, or clinical deterioration 9. In low income countries, the dual burden of communicable and non-communicable diseases poses an additional challenge, since ACS may be misdiagnosed as a communicable disease, such as pulmonary tuberculosis 17.…”

“…In low income countries, the dual burden of communicable and non-communicable diseases poses an additional challenge, since ACS may be misdiagnosed as a communicable disease, such as pulmonary tuberculosis 17. In rural and low-income countries, resources are another barrier, as misdiagnosis is common in environments without direct access to (a facility with) tests critical for diagnosing ACS, such as ECG and serum troponin testing 816…”

“…In clinical practice, almost a third of cases are initially misdiagnosed, which drops to ~1% after clinical evaluation and risk stratification789…”