When the history of acute myocardial infarction is typical, the initial electrocardiogram abnormal and followed by defini-tive sequential changes, and MB CK elevated in the initial or subsequent plasma samples with typical sequential changes, the diagnosis is straightforward. A presumptive diagnosis can be made when any two of these criteria are present. Unfortu-nately, however, the diagnosis may be obscure in patients seen very early after the onset of infarction and in those with EC6 manifestations of prior isehemic or other types of heart disease, electrocardiographically silent infarcts, of atypical presenta-tions. Differentiation from ischemia without infarction(unsta-ble angina, aortic stenosis in the elderly, ischemia attributable to right ventricular overload, new-onset angina, or inadequate myocardial perfusion in markedly hypertrophied left ventricles or in association with marked aortic insufficiency), and from pericarditis with pain simulating that of infarction may be dif-ficult without the aid of laboratory tests and cardiac imaging. A critical differential diagnostic consideration is aortic dissec-tion. It should be suspected whenever pain is atypical or not associated with ECG changes typical of infarction.

Pleurodynia pulmonary embolism or infarction, pneu-mothorax, pneumonitis, musculoskeletal pain associated with bursitis, the shoulder/hand syndrome, pectoral lym-phadenopathy, herpes zoster before eruption of the typical vesicles, myalgia, and costochondritis may simulate infarction superficially but can usually be differentiated easily on the basis of physical findings, results of laboratory tests, and chest ra-diography. Pain of abdominal origin that may masquerade as infarction includes that caused by cholecystitis or cholelithiasis, pancreatitis, duodenal or gastric ulcer, gastritis, esophagitis, esophageal spasm, or esophageal reflux associated with a hiatal hernia(Table 12).

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