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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 68-71

Acute provoked pulmonary embolism masquerading as inferior wall myocardial infarction with right ventricular infarction


Department of Cardiology, AIIMS, Bhubaneswar, Odisha, India

Date of Submission14-May-2021
Date of Decision15-May-2021
Date of Acceptance17-May-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Debasish Das
Department of Cardiology, AIIMS, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_32_21

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  Abstract 


We present an extreme rare case of acute pulmonary embolism in an 83-year-old male presenting as acute inferior wall ST-elevated myocardial infarction with right ventricular infarction (RVMI) in electrocardiogram (ECG). Acute pulmonary embolism presenting as acute inferior wall ST-elevation myocardial infarction with RVMI has not been described in the world literature so far. Our case is unique and first to describe the presentation of acute pulmonary embolism in the form of inferior wall ST-elevated myocardial infarction with evidence of RVMI in the ECG. It is of utmost important for the treating cardiologist and critical care physician to differentiate the same as treatment modalities of both conditions varies markedly and wrong therapeutic measures can land up in a catastrophe.

Keywords: Embolism, myocardial infarction, pulmonary, right, ventricular


How to cite this article:
Das T, Das D, Acharya D, Singh S, Gupta JD, Pramanik S. Acute provoked pulmonary embolism masquerading as inferior wall myocardial infarction with right ventricular infarction. Res Cardiovasc Med 2021;10:68-71

How to cite this URL:
Das T, Das D, Acharya D, Singh S, Gupta JD, Pramanik S. Acute provoked pulmonary embolism masquerading as inferior wall myocardial infarction with right ventricular infarction. Res Cardiovasc Med [serial online] 2021 [cited 2021 Dec 4];10:68-71. Available from: https://www.rcvmonline.com/text.asp?2021/10/2/68/322583




  Introduction Top


Acute pulmonary embolism in electrocardiogram (EKG) presents with sinus tachycardia, new right bundle branch block, right axis deviation, S1Q3T3 pattern, ST elevation in V1 and aVR, atrial premature contractions (APCs), atrial fibrillation or flutter. Most of the EKG changes in acute pulmonary embolism reflect acute right ventricular strain. Acute pulmonary embolism if at all presents mimicking myocardial infarction, EKG most commonly resembles that of anterior wall myocardial infarction. Although few cases of acute pulmonary embolism presenting as inferior wall myocardial infarction have been described, our case is first to describe unique presentation of acute pulmonary embolism mimicking inferior wall myocardial infarction with right ventricular infarction in an octagenerian.


  Case Report Top


A 83-year-old male nondiabetic, hypertensive, smoker, known case of COPD presented to the medicine outpatient department with acute onset shortness of breath for 1 hour with systemic desaturation with SpO2 of 88%. At presentation, he was tachypneic with respiratory rate of 54 per min and he was having tachycardia with heart rate of 120 beats/min with blood pressure of 90/60 mm Hg in the right arm supine position. On cardiac auscultation, he had right ventricular gallop (RVS3) without the presence of LV S4 and respiratory system examination was within the normal limit without the presence of leathery crepitations or bibasal crepitations suggestive of left ventricular systolic dysfunction. EKG revealed presence of ST elevation in III and avF with ST elevation in V1 with the presence of ST depression more than 2 mm in I and aVL suggestive of the presence of inferior wall myocardial infarction with the presence of right ventricular infarction (RVMI) [Figure 1]. However, paradox in the electrocardiogram (ECG) was that patient had ST elevation in aVR without the presence of reciprocal ST-T changes in anterior precordial leads which led us to rethink and we sent for Troponin I evaluation which came out to be negative. ST elevation in aVR pointed toward the presence of pulmonary embolism and the patient was immediately subjected for computed tomography pulmonary angiography which revealed the presence of large thrombus in the left pulmonary artery with thrombus in the distal branch of the right pulmonary artery [Figure 2] and [Figure 3]. COVID reverse transcription polymerase chain reaction was negative. Echocardiography revealed the presence of right atrial (42 [short axis] ×50 mm [long axis]) and right ventricular dilation (basal diameter 48 mm and mid ventricular diameter 42 mm), mild tricuspid regurgitation, mild right ventricular systolic dysfunction (Right ventricular ejection fraction (RVEF) 45%) (Tricuspid annular plane systolic excursion (TAPSE) = 13), regional wall motion abnormality of the basal and mid right ventricular free wall with apical hyper contractility (McConnell's sign), hypercontractile left ventricle with paradoxical septal motion, and dilated inferior vena cava (22 mm).There was no absolute contraindication to thrombolytic therapy in the form of recent intracranial hemorrhage, structural cerebral vascular lesion, intracranial neoplasm, ischemic stroke within 3 months, possible aortic dissection or active bleeding or bleeding diathesis. HAS-BLED score was 2/9, HEMORR2HAGES score was 2/12, CHA2DS2-VASc score was 3. We thrombolysed the patient with Streptokinase 2.5 lakhs unit IV bolus over 30 min followed by 1 lakh unit per h for the next 24 h after which we did the repeat ECG which revealed normalization of ECG changes [Figure 4] with normalization of systemic oxygen saturation with improvement in blood pressure. Although alteplase is preferred to Streptokinase in acute pulmonary embolism if thrombus lysing efficacy is considered, the patient was unaffordable for the same due to financial issues for which we opted for Streptokinase therapy. It was a case of provoked pulmonary embolism as patient provided the history of nonhealing ulcer [Figure 5] in the right leg 4 months back which came out to be squamous cell carcinoma of skin after wide local excision of the same done 1 month back after which he was almost bed ridden producing venous thrombosis with subsequent embolization. Duplex ultrasonography of the lower limb revealed no presence of deep-vein thrombus in the lower limb or in abdomen. Predisposing cancer and prolonged nonambulatory state provoked occult systemic thrombosis with subsequent development of pulmonary embolism. Postthrombolysis we put the patient on low-molecular-weight heparin Enoxaparin 40 mg SC twice daily for 5 days and discharged the patient with oral rivaroxaban 10 mg once daily for 3 months in view of an octagenerian with provoked pulmonary embolism. Our case is unique and first presentation of acute stands for pulmonary embolism (PE) in the form of acute inferior wall myocardial infarction with RVMI recognized and treated successfully in an octogenarian.
Figure 1: Electrocardiogram of acute pulmonary embolism mimicking acute inferior wall myocardial infarction with right ventricular infarction

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Figure 2: Large thrombus in the left pulmonary artery

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Figure 3: Thrombus in the right distal pulmonary artery and branches

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Figure 4: Post thrombolysis with streptokinase normalization of electrocardiogram changes

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Figure 5: Squamous cell carcinoma of the lower leg as nonhealing ulcer

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  Discussion Top


ECG findings noted during the acute phase of a PE include new right bundle branch block (complete or incomplete), rightward shift of the QRS axis, ST-segment elevation in V1 and aVR, generalized low amplitude QRS complexes, atrial premature contractions, sinus tachycardia, atrial fibrillation/flutter, and T-wave inversions in leads V1-V4.[1] The S1Q3T3 sign (prominent S wave in lead I, Q wave, and inverted T-wave in lead III) is a sign of acute cor pulmonale (acute pressure and volume overload of the right ventricle because of pulmonary hypertension) and reflects right ventricular strain.[2] This ECG finding is present in 15%–25% of patients ultimately diagnosed with pulmonary emboli (PE).[1] Any cause of acute cor pulmonale can result in the S1Q3T3 findings on ECG, including PE, acute bronchospasms, pneumothorax, and other acute lung disorders. The ECG is often abnormal in PE, but findings are neither sensitive nor specific for the diagnosis of PE.[3] The greatest utility of the ECG in a patient with suspected PE is ruling out acute myocardial infarction. Interestingly, our patient had ST elevation in III and aVF mimicking inferior wall ST elevated myocardial infarction with ST elevation in V1 which suggested the presence of RVMI. We thought is not as a case of inferior wall myocardial infarction due to the presence of following features:

  • The presence of ST elevation in aVR pointed toward the presence of pulmonary embolism. Although ST elevation in avR indicates left main coronary artery occlusion, there was no significant ST depression across anterior precordial leads ruling out the same[4]
  • There was no reciprocal ST-T changes in anterior precordial leads ruling out it as inferior wall myocardial infarction[5]
  • We did the ECG of V3R and V4R which did not show ST elevation [Figure 6] which is 88% sensitive and 80% specific for the presence of right ventricular myocardial infarction[6]
    Figure 6: V3 R and V4R showing no ST elevation excluding the presence of right ventricular infarction

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  • The presence of right bundle branch block is not a common finding in inferior wall myocardial infarction, whereas the presence of RBBB points toward the presence of pulmonary embolism.[7]




Ghatak et al.[8] described a case of acute pulmonary embolism presenting as acute anterior wall ST-elevation myocardial infarction (STEMI) with tomb stoning appearance of ECG in anterior precordial leads. The ECG changes associated with PE include sinus tachycardia (the most common abnormality), complete or incomplete right bundle branch block, a right ventricular strain pattern (T-wave inversions in the right precordial leads [V1-4] ± the inferior leads [II, III, aVF]), a right axis deviation, or an SI QIII TIII pattern (a deep S-wave in lead I, Q-wave in III, and inverted T-wave in III).[9] The presence of ST elevation is rare and usually suggests massive emboli. Suggested mechanisms for the presence of ST elevation in massive PE.[10],[11],[12] include abrupt elevation of right ventricular pressure and consequently increased right ventricular afterload produced by pulmonary artery outflow obstruction results in right ventricular failure and dilatation inducing myocardial ischemia. These ST elevations could also be explained by a sudden increase in pressure on the right ventricle resulting in stretching of the myocardial cells leading to ischemia and acute coronary vasospasm, resulting in ST elevation. The severe hypoxemia that accompanies massive PE induces a catecholamine surge and further increases myocardial workload, worsening the ischemia. Most of the myocardial infarction like ECG picture of acute pulmonary embolism resembles anterior wall myocardial infarction. In world literature, there exists few case reports of acute pulmonary embolism presenting as inferior wall myocardial infarction but there exists no case description till now as acute pulmonary embolism presenting as inferior wall myocardial with RVMI. Mistry et al.[13] reported a case of acute pulmonary embolism presenting as inferior wall myocardial infarction, but they did not report the presence of feature of associated RVMI as there was no ST elevation in V1. Emren et al.[14] described a case of acute pulmonary embolism presenting as inferior wall myocardial infarction but they did not describe the associated feature of RVMI. Our case is unique and first to describe the EKG presentation of acute pulmonary embolism in the form of acute inferior wall STEMI with features of RVMI. Young cardiologists and emergency physicians must be aware of the differentiating feature between the two to salvage the patient with an emergency thrombolytic therapy with streptokinase or alteplase in pulmonary embolism or proceed for primary PCI in the event of acute ST-elevated myocardial infarction. EKG in the pulmonary embolism also masquerades complicated inferior wall myocardial infarction.


  Conclusion Top


We are presenting an extremely rare and unusual presentation of acute pulmonary embolism mimicking acute inferior wall myocardial infarction with RVMI. Pulmonary embolism presenting as acute inferior wall MI and RVMI has not been described in world literature so far. Critical differentiation of both conditions in EKG saves the life with proper therapeutic measures achieving good outcome; an age-old saying is there “pulmonary embolism really masquerades from simple sinus tachycardia to myocardial infarction.”

Ethical clearance

Due ethical clearance has been obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ullman E, Brady WJ, Perron AD, Chan T, Mattu A. Electrocardiographic manifestations of pulmonary embolism. Am J Emerg Med 2001;19:514-9.  Back to cited text no. 1
    
2.
Chan TC, Vilke GM, Pollack M, Brady WJ. Electrocardiographic manifestations: Pulmonary embolism. J Emerg Med 2001;21:263-70.  Back to cited text no. 2
    
3.
Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P, et al. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol 2000;86:807-9, A10.  Back to cited text no. 3
    
4.
Zhong-Qun Z, Chong-quan W, Nikus KC, Sclarovsky S, Chao-rong H. A new electrocardiogram finding for massive pulmonary embolism: ST elevation in lead aVR with ST depression in leads I and V4 to V6. Am J Emerg Med 2013;31:456.E5-456, E8.  Back to cited text no. 4
    
5.
Parale GP, Kulkarni PM, Khade SK, Athawale S, Vora A. Importance of reciprocal leads in acute myocardial infarction. J Assoc Physicians India 2004;52:376-9.  Back to cited text no. 5
    
6.
Nagam MR, Vinson DR, Levis JT. ECG diagnosis: Right ventricular myocardial infarction. Perm J 2017;21:16-105.  Back to cited text no. 6
    
7.
Petrov DB. Appearance of right bundle branch block in electrocardiograms of patients with pulmonary embolism as a marker for obstruction of the main pulmonary trunk. J Electrocardiol 2001;34:185-8.  Back to cited text no. 7
    
8.
Ghatak A, Alsulaimi A, Acosta YM, Ferreira A. Acute pulmonary embolism masquerading as acute myocardial infarction. Proc (Bayl Univ Med Cent) 2015;28:69-70.  Back to cited text no. 8
    
9.
Brooks H, Kirk ES, Vokonas PS, Urschel CW, Sonnenblick EH. Performance of the right ventricle under stress: Relation to right coronary flow. J Clin Invest 1971;50:2176-83.  Back to cited text no. 9
    
10.
Falterman TJ, Martinez JA, Daberkow D, Weiss LD. Pulmonary embolism with ST segment elevation in leads V1 to V4: Case report and review of the literature regarding electrocardiographic changes in acute pulmonary embolism. J Emerg Med 2001;21:255-61.  Back to cited text no. 10
    
11.
Panos RJ, Barish RA, Whye DW Jr., Groleau G. The electrocardiographic manifestations of pulmonary embolism. J Emerg Med 1988;6:301-7.  Back to cited text no. 11
    
12.
Vranckx P, Ector H, Heidbuchel H. A case of extensive pulmonary embolism presenting as an acute myocardial infarction. Eur J Emerg Med 1998;5:253-8.  Back to cited text no. 12
    
13.
Mistry A, Natarajan N, Hussain S, et al. Unusual presentation of acute pulmonary embolus presenting with inferior ST elevation. BMJ Case Rep 2018;10:1-2.  Back to cited text no. 13
    
14.
Emren SV, Arıkan ME, Senöz O, Varış E, Akan E. Acute pulmonary embolism mimicking inferior myocardial infarction. Turk Kardiyol Dern Ars 2014;42:290-3.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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