Pulmonary thromboembolism initially mistaken for inferior STEMI
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ctrocardiographic changes can be seen in the majority of patients with pulmonary embolism, varying from sinus tachycardia and nonspecific precordial T-wave changes to typical S1Q3T3. In rare cases it can mimic anteroseptal myocardial infarction (MI) with ST elevation in leads V1–V4. ST elevation in the inferior leads has also been reported but is extremely rare. Here we describe a case of pulmonary embolism that mimicked inferior and right ventricular (RV) infarction with ST elevation in the inferior leads and V3R–V5R.
A. Bozorgi · Z. Rahnamoun Tehran Heart Center, Tehran University of Medical Science, Tehran
Pulmonary thromboembolism initially mistaken for inferior STEMI phy via the right femoral artery at another center, demonstrating a normal right coronary artery without significant lesions (. Fig. 4). Color Doppler sonography was performed revealing acute proximal left lower limb deep vein thrombosis (DVT). Transthoracic echocardiography showed a normal left ventricular function without regional wall motion abnormalities. The right ventricle was mildly dilated with mild systolic dysfunction and a pulmonary arterial pressure of 40 mmHg. There was dyskinesia of the RV free wall,
with the apex being spared. Pulmonary CT angiography revealed bilateral pulmonary embolism (. Fig. 5). Cardiac enzymes were mildly elevated without a significant subsequent rise. The patient received IV anticoagulant medication and warfarin and remained asymptomatic at the 2-month follow-up.
Discussion ST elevation in pulmonary thromboembolism (PTE) occurs only on rare occa-
Case report A 66-year-old woman presented to our emergency department with acute onset of chest pain and dyspnea that had started 6 h earlier. Initial ECG revealed sinus tachycardia with slight ST elevation in leads I and aVF and reciprocal ST depression in leads I and aVL (. Fig. 1), which were absent on the patient’s ECG 1 day before presentation (. Fig. 2). Right-sided ECG also showed ST elevation in leads V3R–V5R (. Fig. 3). On physical examination, she was oriented without respiratory distress with a blood pressure of 120/70 mm Hg, a heart rate of 113 beats/min, and a respiratory rate of 32 breaths/min. The O2 saturation rate without supplemental oxygen was 92%. No abnormality was detected during a rapid examination, except for the left lower extremity that was swollen and edematous. One day before presentation, the patient had undergone coronary angiogra-
Fig. 1 8 Initial electrocardiogram at presentation showing ST elevation in leads I, aVF and ST depression in leads I, aVL
Fig. 2 8 Electrocardiogram 1 day before presentation; note the absence of ST changes Herz 5 · 2013
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e-Herz: Case study
Fig. 3 8 Right-sided electrocardiogram showing ST elevation in leads V3R– V5R
Fig. 4 8 Coronary angiography on the day before presentation; RCA appears normal except for plaque in the midportion
Fig. 5 9 Pulmonary CT angiography revealing bilateral pulmonary thromboembolism
sions. The anteroseptal leads are most likely to show it. In a study of Stein and c
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