Pulmonary Embolism Presenting as ST-Elevation Myocardial Infarction: A Diagnostic Trap

Abstract

Patient: Male, 50-year-old Final Diagnosis: Submassive pulmonary embolism Symptoms: Chest pain • dyspnea Medication: — Clinical Procedure: Cardiac catheterization Specialty: Cardiology • Critical Care Medicine • Pulmonology Objective: Challenging differential diagnosis Background: The clinical presentation of pulmonary embolism (PE) is highly variable, ranging from no symptoms to shock or sudden death, often making the diagnosis a challenge. An electrocardiogram (EKG) is not a definitive diagnostic tool; however, it can alter the clinical suspicion of acute PE. PE has nonspecific electrocardiographic patterns ranging from a normal EKG in almost 33% of patients to sinus tachycardia, S1Q3T3 pattern (McGinn-White Sign), right axis deviation, and incomplete right bundle branch block (RBBB). ST-segment elevation associated with PE is exceedingly rare, and to date, only a few cases have been reported. Case Report: We present a case of a middle-aged male patient with no medical comorbidities other than obesity, who presented with initial symptoms and EKG findings concerning an ST-elevation myocardial infarction (STEMI). He was later found to have rather patent coronary arteries on cardiac catheterization but bilateral sub-massive pulmonary embolism on computed tomography angiogram (CTA) of the chest. Conclusions: The differential diagnosis of STEMI is broad, including, but not limited to, Prinzmetal’s angina, takotsubo cardiomyopathy, Brugada syndrome, left ventricular aneurysm, hypothermia, hyperkalemia, and acute pericarditis. Pulmonary embolism may present with abnormal EKG and biomarkers that appear to be an acute coronary syndrome, even STEMI. Physicians must maintain a high index of clinical suspicion through risk stratification to identify PE in these settings, as the frequency of such an occurrence is extremely low. A bedside echocardiogram can be an invaluable diagnostic tool in such cases.

A Rare Case of Pulmonary Emboli Presenting With ST Elevation on ECG

“…Other proposes that Paradoxical embolization can occur especially with patent foramen ovale in the setting of PE leading to coronary occlusion [ 7 ]. catecholamine surge induced by severe hypoxemia leading to increase myocardial work is another possible mechanism [ 8 ]. The echocardiogram in our case showed right ventricular overload and the coronary angiogram did not show any occlusion of the coronary arteries.…”

“Obesity paradox” and takotsubo syndrome

“…The PubMed was employed from its inception to 9/6/22 in response to MeHS “obesity and takotsubo” and 29 articles were accessed [ 2 , 3 , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] ]; in addition, a recently published article with reference to morbid obesity [ 36 ] was included, for a total of 30 articles. A meta-analysis could not be performed, since many of the accessed articles ( Table 1 ) did not comprise granular (individual patient-based) information on obesity.…”

“… 22. [ 29 ] A case report of an obese (BMI 37 kg/m 2 ) 50-year-old man with TTS in the setting of a bilateral submassive pulmonary embolism. 23.…”

Myopericarditis Mimicking an Acute MI

“…Chest pain with ST elevations in contigious leads is usually considered to be acute myocardial infarction (MI) until proven otherwise. However, ST elevations are not pathognomonic to MI; there are other conditions like pericarditis [2], pulmonary embolism, pneumothorax, subarachnoid hemorrhage, hypertrophic and takotsubo cardiomyopathy, aortic dissection, and acute pancreatitis that can also cause ST elevations [3][4][5][6]. ST elevation on an electrocardiogram can be the presenting sign of a diagnosis that carries a poor prognosis if not managed promptly.…”