ST

A 95 year old man is sent from clinic to the emergency department with a preliminary plan of "rule out TB." He has multiple medical problems including HTN, hyperlipidemia, COPD, chronic kidney disease, arthritis, GERD, and a positive PPD and presents with hemoptysis of one month. On further history, he has no chest pain or shortness of breath, but feels that a week or two ago, he suddenly became very weak. As is routine in the ED, they get an EKG simply because the patient is old.

I don't have his exact EKG but I found one that is similar and it is shown above. The ED sees this EKG and calls a STEMI code - they read this as an acute heart attack. His troponin is 0.3 (creatinine is 2). The interventional cardiology fellow comes and is about to whisk the patient away to the cath lab when the family says perhaps angiography and stent is not consistent with the patient's goals of care. They decide to medically manage this STEMI without aggressive intervention. We are called to admit this patient to the general cardiology floor.

The EKG above is not the patient's EKG, but when I looked at the patient's EKG, I also noted some ST elevation in the inferior leads and no reciprocal changes. As a result, I started worrying that this was not a STEMI as advertised but possibly percarditis. It is odd, however, that the patient had no chest pain whatsoever.

When the attending reviewed the EKG and the story the next day, however, he became suspicious that this was neither a STEMI nor pericarditis. Although those are the two most common causes for ST elevation on an EKG, a much rarer diagnosis can do it as well. It turns out that this patient had an LV aneurysm; he likely had an old MI a week or two ago with persistent troponins due to his chronic kidney disease. During the interim, he developed a large LV aneurysm which lead to the false STEMI activation.

This case was a fascinating lesson in EKG interpretation; context is so, so important to diagnosis.

EKG is from wikidoc.org, shown under Fair Use.