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 .
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.
Dr.S.Venkatesan MD 