CLINICAL COMMUNICATION TO THE EDITOR
Early Repolarization Masquerading as STEMI To the Editor: A 46-year-old man presented to the Emergency Department for chest pain and perianal pain. His blood pressure was 125/79 mm Hg; heart rate was 86 beats per minute. An electrocardiogram (ECG) revealed ST-segment elevation in the inferior and lateral leads (Figure, panel A). Repeat ECG 5 minutes later was identical. Troponin T was elevated at 0.13 ng/mL. ST-elevation myocardial infarction (STEMI) was diagnosed and the patient went immediately to the cardiac catheterization laboratory for revascularization. At angiography, coronary arteries were entirely normal, without any evidence of coronary artery disease. Left ventricular ejection fraction was 0.56; wall motion was completely normal. Left ventricular volumes were 88 mL at end-diastole and 39 mL at end-systole. After STEMI was ruled out, he had an incision and drainage of a perirectal abscess. ECG the next day showed classic changes of early repolarization (Figure, panel B). The patient had no family history of atherosclerotic vascular disease and had never smoked. Glycosylated hemoglobin (commonly called hemoglobin A1c) was 5.8%, total cholesterol was 107 mg/dL, low-density lipoprotein 66 mg/dL, triglycerides 69 mg/dL, and high-density lipoprotein 27 mg/dL. The patient made a rapid, complete recovery without incident. At time of discharge, the ECG was normal, without any changes of repolarization. Intermittent presence of ECG changes of early repolarization has been described.1,2
Funding: None. Conflicts of Interest: None. Authorship: All authors had access to the data. All authors had a role in writing the manuscript, have read the manuscript, and agree with its content. Requests for reprints should be addressed to Shahbudin H. Rahmitoola, MB, FRCP, DSc (Hon), LAC USC Medical Center, Old GNH Room 3221, Los Angeles, CA 90033. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
Figure (A) Part of an electrocardiogram (ECG) showing ST elevation with prominent tall T waves in leads II, III, aVF, V4-6. The rest of the leads were normal. (B) Part of an ECG showing changes of early repolarization in leads V4-6 (marked by an arrow). The rest of the leads were normal.
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The American Journal of Medicine, Vol 127, No 11, November 2014 Lucas Christianson, MD Ray V. Matthews, MD Shahbudin H. Rahmitoola, MB, DSc (Hon) Griffith Center Division of Cardiovascular Medicine Department of Medicine LAC+USC Medical Center Keck School of Medicine University of Southern California Los Angeles
http://dx.doi.org/10.1016/j.amjmed.2014.07.008
References 1. Derval N, Simpson CS, Birnie DH, et al. Prevalence and characteristics of early repolarization in the CASPER. J Am Coll Cardiol. 2011;58(7): 722-728. 2. Choudhuri I, Pinninti M, Marwali MR, Sra J, Akhtar M. Polymorphic ventricular tachycardia—part II: the channelopathies. Curr Probl Cardiol. 2013;38(12):503-548.
Early Repolarization Masquerading as STEMI To the Editor: A 46-year-old man presented to the Emergency Department for chest pain and perianal pain. His blood pressure was 125/79 mm Hg; heart rate was 86 beats per minute. An electrocardiogram (ECG) revealed ST-segment elevation in the inferior and lateral leads (Figure, panel A). Repeat ECG 5 minutes later was identical. Troponin T was elevated at 0.13 ng/mL. ST-elevation myocardial infarction (STEMI) was diagnosed and the patient went immediately to the cardiac catheterization laboratory for revascularization. At angiography, coronary arteries were entirely normal, without any evidence of coronary artery disease. Left ventricular ejection fraction was 0.56; wall motion was completely normal. Left ventricular volumes were 88 mL at end-diastole and 39 mL at end-systole. After STEMI was ruled out, he had an incision and drainage of a perirectal abscess. ECG the next day showed classic changes of early repolarization (Figure, panel B). The patient had no family history of atherosclerotic vascular disease and had never smoked. Glycosylated hemoglobin (commonly called hemoglobin A1c) was 5.8%, total cholesterol was 107 mg/dL, low-density lipoprotein 66 mg/dL, triglycerides 69 mg/dL, and high-density lipoprotein 27 mg/dL. The patient made a rapid, complete recovery without incident. At time of discharge, the ECG was normal, without any changes of repolarization. Intermittent presence of ECG changes of early repolarization has been described.1,2
Funding: None. Conflicts of Interest: None. Authorship: All authors had access to the data. All authors had a role in writing the manuscript, have read the manuscript, and agree with its content. Requests for reprints should be addressed to Shahbudin H. Rahmitoola, MB, FRCP, DSc (Hon), LAC USC Medical Center, Old GNH Room 3221, Los Angeles, CA 90033. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
Figure (A) Part of an electrocardiogram (ECG) showing ST elevation with prominent tall T waves in leads II, III, aVF, V4-6. The rest of the leads were normal. (B) Part of an ECG showing changes of early repolarization in leads V4-6 (marked by an arrow). The rest of the leads were normal.
e2
The American Journal of Medicine, Vol 127, No 11, November 2014 Lucas Christianson, MD Ray V. Matthews, MD Shahbudin H. Rahmitoola, MB, DSc (Hon) Griffith Center Division of Cardiovascular Medicine Department of Medicine LAC+USC Medical Center Keck School of Medicine University of Southern California Los Angeles
http://dx.doi.org/10.1016/j.amjmed.2014.07.008
References 1. Derval N, Simpson CS, Birnie DH, et al. Prevalence and characteristics of early repolarization in the CASPER. J Am Coll Cardiol. 2011;58(7): 722-728. 2. Choudhuri I, Pinninti M, Marwali MR, Sra J, Akhtar M. Polymorphic ventricular tachycardia—part II: the channelopathies. Curr Probl Cardiol. 2013;38(12):503-548.
