Acute Inferior Myocardial Infarction or Not?

Abstract

A patient in their 50s presented to the emergency department with a 3-day history of confusion and falls. The patient had type 2 diabetes treated with empagliflozin, 25 mg daily; metformin, 1000 mg twice daily; and glipizide, 5 mg daily. Initial evaluation revealed a heart rate of 102 beats/min, blood pressure of 143/98 mm Hg, oxygen saturation of 100%, temperature of 36.6 °C, and confusion. A 12-lead electrocardiogram (ECG) was obtained in the emergency department (Figure , A).Questions: What are the notable findings on the patient's initial ECG? What conditions can cause these ECG abnormalities?

Maybe Not an Acute Inferior Myocardial Infarction—Reply

“…In Reply We appreciate the opportunity to respond to the insightful comments from Drs Cao and Wu regarding our recent report . We agree with the authors that there is a possibility that acidosis-induced paroxysmal atrioventricular block caused the patient’s prehospital symptoms.…”

“…We have re-examined the coronary angiogram (performed during ST-segment elevation) and found no evidence for epicardial spasm or diminished thrombolysis in myocardial infarction flow in any of the coronary arteries. As we noted in the case report, the morphology of the ST-segment elevation is not typical of that seen with inferior transmural myocardial ischemia . Nonetheless, as Drs Cao and Wu point out, provocative testing was not performed; therefore, coronary artery spasm cannot be excluded with certainty.…”

Maybe Not an Acute Inferior Myocardial Infarction

“…To the Editor This letter is in response to the Challenges in Clinical Electrocardiography report by Jay and colleagues who described an interesting case of sodium-glucose cotransporter-2 inhibitor–associated euglycemic diabetic ketoacidosis and its effect on the electrocardiogram (ECG). We would like to commend the authors for sharing their observations and discussing ST-segment elevation mimicking acute myocardial infarction during euglycemic diabetic ketoacidosis.…”

“…Second, Jay and colleagues considered regional ST-segment elevation mimicking acute myocardial infarction arising from metabolic acidosis that resulted in a loss of depolarizing currents during the plateau phase of the action potential and depression of the epicardial action potential dome. We agree with this point.…”