suggestive of ST-segment elevation myocardial infarction in patients who were found not to have ST-segment elevation myocardial infarction. 1 Typical of those cases were a critical illness, a unique dome-and-spike pattern always in the inferior leads, and high in-hospital mortality.We recently reported a case in which the "spiked helmet" sign appeared in the anteroapical leads ( Figure). 2 Coronary angiography excluded coronary artery disease as a cause of ST-segment elevation. The cause of death, as established by autopsy, was traumatic aortic dissection due to a car accident. The morphology of the ST-segment elevation resembled the second case in the series of Littmann and Monroe. The exact mechanism of this pseudo-STsegment elevation is not known, but in the case of inferior ST-segment elevation, the proposed mechanism was diaphragmatic movement or an acute rise in intra-abdominal pressure. In our case, an acute rise in intrathoracic pressure due to aortic dissection may have been the cause of the pseudo-ST-segment elevation. In reply: We thank Tomcsányi et al for their interest in our work. The presented case extends our observations by demonstrating that with a sudden rise in intrathoracic pressure, the spiked helmet pattern can also show up in the chest leads. As was typical of our series, their patient did not have myocardial infarction (according to standard diagnostic criteria) and did not survive to hospital discharge. Our purpose in describing the spiked helmet sign was to raise physician awareness of this potential electrocardiographic marker of a high risk of death. 1 We hope that if physicians can recognize the spiked helmet sign in real time, it will assist in the rapid evaluation and management of critically ill patients. The case presented by Tomcsányi et al is a further step in this direction.
FIGURE.The "spiked helmet" sign. Atrial fibrillation and ST-segment elevation in leads V 2 through V 4 . The dome-and-spike sign is most pronounced in leads V 3 and V 4 . Reprinted from J Electrocardiol, 2 with permission from Elsevier.
A significant increase in NT-proBNP levels is to be expected in early repeated measurement after hospital admission. This fact could have diagnostic and prognostic consequences if validated in a larger patient population. Orv Hetil. 2018; 159(25): 1009-1012.
We report a new entity of the Takotsubo syndrome. While the classic form of Takotsubo syndrome presents as transient apical ballooning, in reverse Takotsubo syndrome we see just the opposite, i.e. transient dilatation of the basal segments and a hyperkinetic apex. The reverse Takotsubo phenomenon was seen in a 36-year-old female patient who had an injection of lidocaine with adrenaline for plastic surgery of the ear. Coronary artery disease was excluded as the cause of this patient's prolonged chest pain and troponin positivity. Echocardiography revealed akinesis of the basal segments and a hyperkinetic apex. The wall motion abnormalities resolved in three days.
ST-segment elevation is the hallmark of acute transmural myocardial ischemia caused by acute occlusion of a coronary artery. ST-segment elevation is the major criterion for the patients with chest pain to immediate reperfusion therapy. Despite its clinical importance, the mechanism of ST-elevation remains unclear. Two patients are reported with proximal left anterior descending coronary occlusion but without ST-segment elevation. The distinct ECG patterns were tall, with symmetrical T-waves and upsloping and digoxin-like ST-segment depression. Patients with these ECG patterns need immediate coronary intervention.
The presented cases shed light to the fact that the apical dilatation of the left ventricle is only one of the possible presentations of stress induced cardiomyopathy. The main feature of this entity is not the tako-tsubo-like left ventricular dilatation, which is not always present, but the almost universal QT prolongation and negative T waves. These ECG features come a few days after the appearance of the reversible left ventricular dysfunction.
A 42-year-old man is presented with acute coronary syndrome and De Winter ECG sign. The De Winter sign is a rare ECG manifestation of proximal LAD occlusion. The ECG sign was misinterpreted and the patient was transmitted to our percutan coronaria intervention centrum with 3 hours delay. The hyperacute T-waves and the precordial ST-depressions disappeared, but the biomarkers showed a marked elevation. Coronary angiography revealed LAD proximal thrombotic dissection treated with a drug-eluting stent. The authors suggest that in patients with this ECG pattern the immediate coronary intervention is the best treatment. Orv Hetil. 2019; 160(43): 1711–1713.
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