Case report and systematic review of pulmonary embolism mimicking ST-elevation myocardial infarction

Abstract

Background To study trends in the clinical presentation, electrocardiograms, and diagnostic imaging in patients with pulmonary embolism presenting as ST segment elevation. Methods We performed a systematic literature search for all reported cases of pulmonary embolism mimicking ST-elevation myocardial infarction. Pre-specified data such as clinical presentation, electrocardiogram changes, transthoracic echocardiographic findings, cardiac biomarkers, diagnostic imaging, therapy, and outcomes were collected. Results We identified a total of 34 case reports. There were 23 males. Mean age of the population was 56.5 ± 15.5 years. Patients presented with dyspnea (76.4%), chest pain (63.6%), and tachycardia (71.4%). All patients presented with ST-elevations, with the most common location being in the anterior-septal distribution, lead V3 (74%), V2 (71%), V1 (62%) and V4 (47%). ST-segment elevations in the inferior distribution were present in lead II (12%), III (18%), and aVF (21%). Presentation was least likely in the lateral distribution. Troponin was elevated in 78.9% of cases. Right ventricular strain was the most common echocardiographic finding. Over 80% of patients had findings consistent with elevated right ventricular pressure, with 50% reported RV dilatation and 20% RV hypokinesis. The most commonly used imaging modality was contrast-enhanced pulmonary angiography. There was a greater incidence of bilateral compared to unilateral pulmonary emboli (72.4% vs. 10%). About 65% patients received anticoagulation and 36.3% were treated with thrombolytics. Forty-six percent of patients required intensive care and 18.7% intubation. Overall mortality was 25.8%. Conclusions A review of the literature reveals that in patients presenting with pulmonary embolism, electrocardiogram findings of ST-segment elevations will occur predominantly in the anterior-septal distribution.

Atypical manifestations of pulmonary embolism

“…The diagnosis of PE was validated by CTPA, ventilation/perfusion scintigraphy, angiography, and autopsy, in 6,2,17, and in 8 subjects, respectively. The Wells score for PE amounted to < 2 in 44.4% of the 27 patients in whom that parameter was measured [13].…”

“…This presentation can simulate acute coronary syndrome, especially in the presence of elevation in serum troponin levels and concurrent ST segment depression and/ or T wave inversion [12]. Diagnostic confusion is compounded by the fact that PE can also present with electrocardiographic (ECG) stigmata simulating ST segment elevation myocardial infarction (STEMI) in the absence of concurrent coronary artery occlusion [13]. In the latter review of this phenomenon, the STEMI stigmata occurred most frequently in leads V1-V4, less frequently in the inferior leads II, III, and AVF, and least frequently in leads V5 and V6.…”

What Are the Parameters That Should Inform Gestalt as a Clinical Decision Strategy for Pulmonary Embolism?

“…2 An important caveat to unstructured diagnostic evaluation is that gestalt is operator-dependent and not necessarily also dependent on awareness of atypical symptoms of pulmonary embolism such as abdominal pain 3,4 and ST segment elevation, 5 so as to mitigate the risk of inappropriate laparotomy 3 or inappropriate coronary angiography. 5 In 1957, pulmonary embolism-related abdominal pain was documented as having a 12% prevalence among 90 patients with pulmonary embolism. 3 More recently, 9.5% of 40 patients with pulmonary embolism were documented as having presented with abdominal pain in the absence of concurrent chest pain or dyspnea.…”

“…4 A recent review of the world literature documented 34 cases of pulmonary embolism-related electrocardiographic ST segment elevation in the absence of thrombotic coronary artery occlusion or thrombotic coronary artery occlusion attributable to paradoxical embolism. 5 The Wells score amounted to < 2 in 44.4% of the 27 patients in whom that parameter was measured. 5 Gestalt should, therefore, be informed, not only by awareness of classical symptoms and signs of pulmonary embolism but also by awareness of atypical clinical stigmata, exemplified by pulmonary embolism-related abdominal pain, 3,4 pulmonary embolism-related ST segment elevation, 5 and the association of pulmonary embolismrelated abdominal pain and pulmonary embolism-related ST segment elevation.…”

“…5 The Wells score amounted to < 2 in 44.4% of the 27 patients in whom that parameter was measured. 5 Gestalt should, therefore, be informed, not only by awareness of classical symptoms and signs of pulmonary embolism but also by awareness of atypical clinical stigmata, exemplified by pulmonary embolism-related abdominal pain, 3,4 pulmonary embolism-related ST segment elevation, 5 and the association of pulmonary embolismrelated abdominal pain and pulmonary embolism-related ST segment elevation. 6…”