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Erratic coronary care : It is almost a STEMI !

Posted Dec 31 2012 11:39am

A 60 year old man with chest discomfort and severe breathlessness  and  blood pressure of 160/110 was  wheeled into CCU. A diagnosis of  acute anterior  STEMI was made and he  was about to be  thrombolysed . Since  his blood pressure was high they were waiting for it to come down with IV  Nitrglycerin

I was called to see this  patient  .Here is his ECG .

Q-LVH INCOMPLET LBBB STEMI DIFFERENTIAL DIAGNOSIS 2

Though   ECG  suggested anterior  STEMI  , I  was  fairly  convinced  it  was  in fact  LVH and  incomplete  LBBB.

I confirmed with the  patient  about the onset of symptoms . It was primarily  breathlessness and only a  vague discomfort .Meanwhile , the troponin came as positive and CPK MB    was  normal. The combined troponin  positivity  and ST elevation  almost confirmed the STEMI ,  and  the  urgency for  thrombolysis was  intensified . One resident suggested  an  emergency PCI.

My self ,  in spite of  being a cardiologist was isolated among the physician team .  I  had to  urgently  prove to them it is indeed  not STEMI !  I did a bed side echo and showed  the  physician colleagues   a vigorously contracting  hypertrophied  left ventricle  with a EF of 68 % . There  was  negligible wall motion defect  . . .  if at all any !

They were still far from convinced ?  They  were  sort of  amused .There is   ST elevation ,  there is  troponin  positivity. . . what else you want  . . . they seemed to ask  ?

I asked them  . . . How can an  acute  extensive anterior   MI contract so well ,  without a trace of   wall motion defect ?

It took me considerable time and effort  to  convince them  that the whole thing was not a STEMI.  Finally they agreed .It was  a simple LVH with secondary ST elevation  due to incomplete  LBBB .  Troponin elevation  simply  represent minor myocardial  injury associated  with hypertensive  LVF . This  patient was discharged within 24 hours  in perfectly stable  condition . Since he had mild elevation of creatinine and was  sent for  nephrology  work up.

Final message

LVH with secondary  ST elevation in V1-V4 is a common situation that mimics  acute STEMI . Cardiac failure can result in non ischemic troponin  release .  Acute medicine is  an unique art . Some times it demands all your senses to be on alert mode . Realise ,  in the above case ,   in spite of the   the classical   triad of  chest pain ,    ST elevation , troponin positivity  it  almost led to a wrong diagnosis of  acute myocardial Infarction .

After thought : What  if they had thrombolysed this patient or taken for a PCI ?

When  the clinical suspicion is high and  circumstantial evidence  point to an ACS   ,   this error can be  justified . After all ,  5 % of   famous ISIS  study population were not suffering from STEMI  but got thrombolysis !

* One real possibility in this ECG is  old AWMI with re-infarction  or a dyskinetic septum lifting the ST segment .But both were excluded by the rapid bed side echo.

 

 

 


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