American Journal of Emergency Medicine 33 (2015) 580–596
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence Acute pulmonary embolism masquerading as inferior myocardial infarction☆
To the Editor, A 57-year-old man recently diagnosed with stage 4 colonic adenocarcinoma was admitted to the hospital for management of large bowel obstruction. During his hospitalization, he developed an episode of profuse sweating during which he had no chest pain and was hemodynamically stable. An electrocardiogram (ECG) was performed (Fig. 1), which showed Q waves and subtle ST-segment elevation (STE) in the inferior leads without reciprocal ST-segment depression. The low suspicion for STE myocardial infarction (STEMI), the presence of risk factor for pulmonary embolism, and awareness that inferior STE is one of the rare ECG manifestations of acute pulmonary embolism (APE) prompted us to perform a computed tomographic (CT) pulmonary angiography, which showed a right main pulmonary artery embolus (Fig. 2). The patient had had an uncomplicated course and was advised for life-long anticoagulation. Acute pulmonary embolism can present with nonspecific symptoms and ECG features leading to delay in diagnosis and worse outcome. Among the rare ECG manifestations in APE is STE, and in this instance, it masquerades as STEMI, which has been the working diagnosis in most reported cases prompting the performance of a coronary angiogram after which the diagnosis of APE is made, if there was no occlusive coronary disease. ST-segment elevation in APE has been reported to occur mainly in the anterior chest leads from V1 to V3 or V4 (V1-V3/V4) [1-11]. Lead V1 faces the anterior wall of the right ventricle (RV) and in cases of RV dilation, lead V2 and sometimes lead V3 face the anterior wall of the RV. In APE, RV transmural ischemia or infarction due to supply/demand mismatch has been the main explanation for STE in this territory [12], and few cases suggested paradoxical coronary embolism through a patent foramen ovale as the cause for anterior STE [6]. We found 4 reports in the English literature that described APE presenting with STE in the inferior leads (Table), 1 met the American College of Cardiology/ American Heart Association criteria for massive APE and 3 for submassive APE [13-16].The explanation for the occurrence of STE in the inferior leads is not very clear. In all 4 cases, the RV was dilated, and in 3 of these cases, the RV was also hypocontractile. In the case that recorded right-sided chest leads ECG, there was STE in V3R to V5R (in absence of right coronary artery disease) suggesting the development of RV transmural ischemia or infarction. In 3 of 4 cases, the working diagnosis was STEMI, and coronary angiography was performed. In the fourth case, a coronary angiogram has been performed a day earlier for different reasons, and the absence of occlusive coronary disease raised suspicion for APE, when inferior STE occurred the next day after the angiogram. Of the 4 described cases, 3 showed either bilateral main or saddle pulmonary emboli: 3 were treated with heparin, and 1 case had mechanical thrombectomy and
☆ There are no conflicts of interest. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
local tissue plasminogen activator due to cardiogenic shock. All but 1 case survived hospitalization. Acute pulmonary embolism should therefore be suspected in all patients with inferior STE who have normal coronary arteries. In cases with inferior STE whose presentation is atypical for myocardial infarction, a CT pulmonary angiography may be useful in diagnosing APE and allowing for immediate initiation of therapeutic doses of anticoagulant therapy. Earlier anticoagulation therapy when started in the emergency department—compared with after admission—has been shown to significantly reduce in-hospital and 30-day mortality rate [17]. This review of reported cases identifies a subset of cases with APE that are intermediate-to-high–risk category for complications and hence the importance of early diagnosis. We therefore aim to emphasize that inferior STE can be one of the ECG manifestations of APE, and the pivotal role of CT pulmonary angiography or bedside echocardiography in cases presenting with STE in the inferior leads, when the presentation is more suggestive of APE or the diagnosis of STEMI is uncertain. Hesham R. Omar, MD Internal Medicine Department, Mercy Medical Center 1410 N, 4th St Clinton Iowa, USA 52732. Tel.: +1 312 714 9272 E-mail address: [email protected] Devanand Mangar, MD Chief of Anesthesia, Tampa General Hospital, Tampa, FL, USA FGTBA CEO and Regional Medical Director TEAMHealth, Knoxville, TN, USA Enrico M. Camporesi, MD University of South Florida, Tampa, FL, USA TEAMHealth, Knoxville, TN, USA http://dx.doi.org/10.1016/j.ajem.2014.11.036 References [1] Falterman TJ, Martinez JA, Daberkow D, Weiss LD. Pulmonary embolism with ST segment elevation in leads V1 to V4: case report and review of the literature regarding electrocardiographic changes in acute pulmonary embolism. J Emerg Med 2001; 21(3):255–61. [2] Livaditis IG, Paraschos M, Dimopoulos K. Massive pulmonary embolism with ST elevation in leads V1-V3 and successful thrombolysis with tenecteplase. Heart 2004;90(7):e41. [3] Lin JF, Li YC, Yang PL. A case of massive pulmonary embolism with ST elevation in leads V1-4. Circ J 2009;73(6):1157–9. [4] Wilson GT, Schaller FA. Pulmonary embolism mimicking anteroseptal acute myocardial infarction. J Am Osteopath Assoc 2008;108(7):344–9. [5] Fasullo S, Paterna S, Di Pasquale P. An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase. J Thromb Thrombolysis 2009;27(2):215–9. [6] Goslar T, Podbregar M. Acute ECG ST-segment elevation mimicking myocardial infarction in a patient with pulmonary embolism. Cardiovasc Ultrasound 2010;8:50. [7] Noble J, Singh A. Asymptomatic pulmonary embolus masquerading as acute anteroseptal myocardial infarction. CJEM 2011;13(1):62–5. [8] Raghav KP, Makkuni P, Figueredo VM. A review of electrocardiography in pulmonary embolism: recognizing pulmonary embolus masquerading as ST-elevation myocardial infarction. Rev Cardiovasc Med 2011;12(3):157–63.
Correspondence
581
Fig. 1. Electrocardiogram in a patient with acute pulmonary embolism showing Q waves and subtle ST-segment elevation in the inferior leads. There is no reciprocal ST-segment depression.
Fig. 2. Computed tomographic pulmonary angiography showing right main pulmonary artery embolism.
[9] Özer N, Yorgun H, Canpolat U, Ateş AH, Aksöyek S. Pulmonary embolism presenting with evolving electrocardiographic abnormalities mimicking anteroseptal myocardial infarction: a case report. Med Princ Pract 2011;20(6):577–80. [10] Montenegro FS, Barzan V, De Lorenzo AR, Pittella FJ, Rocha AS. ST-segment elevation in pulmonary thromboembolism. Arq Bras Cardiol 2012;99(3):e131–3. [11] Barsoum EA, Bhat T, McCord DA, Lafferty J. Uncommon presentation of fatal pulmonary embolism. Angiology 2013;1:106. [12] Zhong-Qun Z, Bo Y, Nikus KC, Pérez-Riera AR, Chong-Quan W, Xian-Ming W. Correlation between ST-segment elevation and negative T waves in the precordial leads in acute pulmonary embolism: insights into serial electrocardiogram changes. Ann Noninvasive Electrocardiol 2014;19(4):398–405. [13] Alsidawi S, Abdalla M, Helmy T. Massive pulmonary embolism with ST-elevation in the inferior leads and other interesting ECG findings. J Biomed Graph Comput 2013;3(1):43–50. [14] Emren SV, Arıkan ME, Senöz O, Varış E, Akan E. Acute pulmonary embolism mimicking inferior myocardial infarction. Turk Kardiyol Dern Ars 2014;42(3):290–3. [15] Obiagwu C, John J, Mastrine L, Borgen E, Shani J. Acute pulmonary embolism masquerading as acute inferior myocardial infarction. J Med Cases 2014;5(2):73–5. [16] Bozorgi A, Rahnamoun Z. Pulmonary thromboembolism initially mistaken for inferior STEMI. Herz 2013;38(5):553–5. [17] Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest 2010;137(6):1382–90.
Table Compilation of cases that had acute pulmonary embolism manifesting with ST-segment elevation in the inferior leads 1st author/year/ reference
Age
Sex
ECG
CTA
RV
Initial working diagnosis
Coronary angiography performed CTA
DVT (site)
Survival
Treatment
Bozorgi/2013/[16]
66
F
STE in I & aVF, V3R-V5R
Dilated, hypokinetic
APE
Y
Heparin
73
M
STE in inferior leads
Dilated, hypokinetic
STEMI
N (had nonocclusive RCA 1 day earlier) Y (nonocclusive disease)
Y (proximal)
Alsidawi/2013/[13]
Bilateral main PA embolus Bilateral APE
NA
N
Emren/2014/[14]
69
M
RLL PA embolism
Dilated
STEMI
Y (nonocclusive disease
85
F
Saddle embolus
Dilated, hypokinetic
STEMI
Y (60% RCA)
Y (proximal) Y (proximal)
Y
Obiagwu/2014/[15]
STE in inferior leads STE in inferior leads
Mechanical thrombectomy, local TPA Heparin
Y
Heparin
Abbreviations: ECG, electrocardiogram; CTA, computed tomography pulmonary angiography; RV, right ventricle; DVT, deep venous thrombosis; STE; ST-segment elevation; PA, pulmonary artery; APE, acute pulmonary embolism; STEMI, ST-segment elevation myocardial infarction; RCA, right coronary artery; F, female; M, male; Y, yes; N, no; NA, not available; TPA, tissue plasminogen activator.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence Acute pulmonary embolism masquerading as inferior myocardial infarction☆
To the Editor, A 57-year-old man recently diagnosed with stage 4 colonic adenocarcinoma was admitted to the hospital for management of large bowel obstruction. During his hospitalization, he developed an episode of profuse sweating during which he had no chest pain and was hemodynamically stable. An electrocardiogram (ECG) was performed (Fig. 1), which showed Q waves and subtle ST-segment elevation (STE) in the inferior leads without reciprocal ST-segment depression. The low suspicion for STE myocardial infarction (STEMI), the presence of risk factor for pulmonary embolism, and awareness that inferior STE is one of the rare ECG manifestations of acute pulmonary embolism (APE) prompted us to perform a computed tomographic (CT) pulmonary angiography, which showed a right main pulmonary artery embolus (Fig. 2). The patient had had an uncomplicated course and was advised for life-long anticoagulation. Acute pulmonary embolism can present with nonspecific symptoms and ECG features leading to delay in diagnosis and worse outcome. Among the rare ECG manifestations in APE is STE, and in this instance, it masquerades as STEMI, which has been the working diagnosis in most reported cases prompting the performance of a coronary angiogram after which the diagnosis of APE is made, if there was no occlusive coronary disease. ST-segment elevation in APE has been reported to occur mainly in the anterior chest leads from V1 to V3 or V4 (V1-V3/V4) [1-11]. Lead V1 faces the anterior wall of the right ventricle (RV) and in cases of RV dilation, lead V2 and sometimes lead V3 face the anterior wall of the RV. In APE, RV transmural ischemia or infarction due to supply/demand mismatch has been the main explanation for STE in this territory [12], and few cases suggested paradoxical coronary embolism through a patent foramen ovale as the cause for anterior STE [6]. We found 4 reports in the English literature that described APE presenting with STE in the inferior leads (Table), 1 met the American College of Cardiology/ American Heart Association criteria for massive APE and 3 for submassive APE [13-16].The explanation for the occurrence of STE in the inferior leads is not very clear. In all 4 cases, the RV was dilated, and in 3 of these cases, the RV was also hypocontractile. In the case that recorded right-sided chest leads ECG, there was STE in V3R to V5R (in absence of right coronary artery disease) suggesting the development of RV transmural ischemia or infarction. In 3 of 4 cases, the working diagnosis was STEMI, and coronary angiography was performed. In the fourth case, a coronary angiogram has been performed a day earlier for different reasons, and the absence of occlusive coronary disease raised suspicion for APE, when inferior STE occurred the next day after the angiogram. Of the 4 described cases, 3 showed either bilateral main or saddle pulmonary emboli: 3 were treated with heparin, and 1 case had mechanical thrombectomy and
☆ There are no conflicts of interest. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
local tissue plasminogen activator due to cardiogenic shock. All but 1 case survived hospitalization. Acute pulmonary embolism should therefore be suspected in all patients with inferior STE who have normal coronary arteries. In cases with inferior STE whose presentation is atypical for myocardial infarction, a CT pulmonary angiography may be useful in diagnosing APE and allowing for immediate initiation of therapeutic doses of anticoagulant therapy. Earlier anticoagulation therapy when started in the emergency department—compared with after admission—has been shown to significantly reduce in-hospital and 30-day mortality rate [17]. This review of reported cases identifies a subset of cases with APE that are intermediate-to-high–risk category for complications and hence the importance of early diagnosis. We therefore aim to emphasize that inferior STE can be one of the ECG manifestations of APE, and the pivotal role of CT pulmonary angiography or bedside echocardiography in cases presenting with STE in the inferior leads, when the presentation is more suggestive of APE or the diagnosis of STEMI is uncertain. Hesham R. Omar, MD Internal Medicine Department, Mercy Medical Center 1410 N, 4th St Clinton Iowa, USA 52732. Tel.: +1 312 714 9272 E-mail address: [email protected] Devanand Mangar, MD Chief of Anesthesia, Tampa General Hospital, Tampa, FL, USA FGTBA CEO and Regional Medical Director TEAMHealth, Knoxville, TN, USA Enrico M. Camporesi, MD University of South Florida, Tampa, FL, USA TEAMHealth, Knoxville, TN, USA http://dx.doi.org/10.1016/j.ajem.2014.11.036 References [1] Falterman TJ, Martinez JA, Daberkow D, Weiss LD. Pulmonary embolism with ST segment elevation in leads V1 to V4: case report and review of the literature regarding electrocardiographic changes in acute pulmonary embolism. J Emerg Med 2001; 21(3):255–61. [2] Livaditis IG, Paraschos M, Dimopoulos K. Massive pulmonary embolism with ST elevation in leads V1-V3 and successful thrombolysis with tenecteplase. Heart 2004;90(7):e41. [3] Lin JF, Li YC, Yang PL. A case of massive pulmonary embolism with ST elevation in leads V1-4. Circ J 2009;73(6):1157–9. [4] Wilson GT, Schaller FA. Pulmonary embolism mimicking anteroseptal acute myocardial infarction. J Am Osteopath Assoc 2008;108(7):344–9. [5] Fasullo S, Paterna S, Di Pasquale P. An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase. J Thromb Thrombolysis 2009;27(2):215–9. [6] Goslar T, Podbregar M. Acute ECG ST-segment elevation mimicking myocardial infarction in a patient with pulmonary embolism. Cardiovasc Ultrasound 2010;8:50. [7] Noble J, Singh A. Asymptomatic pulmonary embolus masquerading as acute anteroseptal myocardial infarction. CJEM 2011;13(1):62–5. [8] Raghav KP, Makkuni P, Figueredo VM. A review of electrocardiography in pulmonary embolism: recognizing pulmonary embolus masquerading as ST-elevation myocardial infarction. Rev Cardiovasc Med 2011;12(3):157–63.
Correspondence
581
Fig. 1. Electrocardiogram in a patient with acute pulmonary embolism showing Q waves and subtle ST-segment elevation in the inferior leads. There is no reciprocal ST-segment depression.
Fig. 2. Computed tomographic pulmonary angiography showing right main pulmonary artery embolism.
[9] Özer N, Yorgun H, Canpolat U, Ateş AH, Aksöyek S. Pulmonary embolism presenting with evolving electrocardiographic abnormalities mimicking anteroseptal myocardial infarction: a case report. Med Princ Pract 2011;20(6):577–80. [10] Montenegro FS, Barzan V, De Lorenzo AR, Pittella FJ, Rocha AS. ST-segment elevation in pulmonary thromboembolism. Arq Bras Cardiol 2012;99(3):e131–3. [11] Barsoum EA, Bhat T, McCord DA, Lafferty J. Uncommon presentation of fatal pulmonary embolism. Angiology 2013;1:106. [12] Zhong-Qun Z, Bo Y, Nikus KC, Pérez-Riera AR, Chong-Quan W, Xian-Ming W. Correlation between ST-segment elevation and negative T waves in the precordial leads in acute pulmonary embolism: insights into serial electrocardiogram changes. Ann Noninvasive Electrocardiol 2014;19(4):398–405. [13] Alsidawi S, Abdalla M, Helmy T. Massive pulmonary embolism with ST-elevation in the inferior leads and other interesting ECG findings. J Biomed Graph Comput 2013;3(1):43–50. [14] Emren SV, Arıkan ME, Senöz O, Varış E, Akan E. Acute pulmonary embolism mimicking inferior myocardial infarction. Turk Kardiyol Dern Ars 2014;42(3):290–3. [15] Obiagwu C, John J, Mastrine L, Borgen E, Shani J. Acute pulmonary embolism masquerading as acute inferior myocardial infarction. J Med Cases 2014;5(2):73–5. [16] Bozorgi A, Rahnamoun Z. Pulmonary thromboembolism initially mistaken for inferior STEMI. Herz 2013;38(5):553–5. [17] Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest 2010;137(6):1382–90.
Table Compilation of cases that had acute pulmonary embolism manifesting with ST-segment elevation in the inferior leads 1st author/year/ reference
Age
Sex
ECG
CTA
RV
Initial working diagnosis
Coronary angiography performed CTA
DVT (site)
Survival
Treatment
Bozorgi/2013/[16]
66
F
STE in I & aVF, V3R-V5R
Dilated, hypokinetic
APE
Y
Heparin
73
M
STE in inferior leads
Dilated, hypokinetic
STEMI
N (had nonocclusive RCA 1 day earlier) Y (nonocclusive disease)
Y (proximal)
Alsidawi/2013/[13]
Bilateral main PA embolus Bilateral APE
NA
N
Emren/2014/[14]
69
M
RLL PA embolism
Dilated
STEMI
Y (nonocclusive disease
85
F
Saddle embolus
Dilated, hypokinetic
STEMI
Y (60% RCA)
Y (proximal) Y (proximal)
Y
Obiagwu/2014/[15]
STE in inferior leads STE in inferior leads
Mechanical thrombectomy, local TPA Heparin
Y
Heparin
Abbreviations: ECG, electrocardiogram; CTA, computed tomography pulmonary angiography; RV, right ventricle; DVT, deep venous thrombosis; STE; ST-segment elevation; PA, pulmonary artery; APE, acute pulmonary embolism; STEMI, ST-segment elevation myocardial infarction; RCA, right coronary artery; F, female; M, male; Y, yes; N, no; NA, not available; TPA, tissue plasminogen activator.
