ST elevation in recovery post exercise with normal coronary arteries

Abstract

We present the case of a 45-year-old healthy man who successfully completed three stages of the Bruce protocol but developed inferolateral ST segment elevation in the recovery phase. The ECG change was associated with a marked drop in blood pressure. He underwent emergency coronary angiography which revealed normal coronary arteries. It is likely that post-exercise hypotension triggered coronary spasm which caused the ST segment elevation. Alternatively, coronary spasm may have been the primary event, inducing sufficient myocardial ischaemia to cause a marked drop in blood pressure. Exercise tolerance testing is often a reliable test to rule out reversible myocardial ischaemia. While the physician is focused on ischaemic changes or rhythm abnormalities developing during the exercise phase, the recovery period is just as important and requires as much vigilance. Coronary vasospasm can result in significant ST changes and haemodynamic compromise at any point during the test, and the ECG traces can be indistinguishable from a classic ST elevation myocardial infarction, as in the present case.

Stress Echo 2030: The Novel ABCDE-(FGLPR) Protocol to Define the Future of Imaging

“…Exclusion criteria are: previous documentation of transient ST segment elevation ≥0.1 mV or depression ≥0.1 mV or appearance of new negative U waves by Holter or 12-lead ECG during spontaneous chest pain; positivity at SE with exercise, dobutamine or vasodilators, with recognition of typical vasospastic positivity during or at recovery of exercise [133]; during infusion or following antidote administration with dobutamine [134]; during infusion or following aminophylline administration with dipyridamole [135]; coronary vasospasm during invasive testing; or resting global LV dysfunction (Wall Motion Score Index >1.4 or ejection fraction <40%).…”