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Electrocardiographic STEMI: A Common but Nonspecific Finding in the ICU
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Electrocardiographic STEMI: A Common but Nonspecific Finding in the ICU To the Editor: Rechenmacher et al1 describe an intubated trauma patient who was noted to have ST-segment elevation in the inferolateral leads. Emergent cardiac catheterization revealed no Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of the manuscript.
coronary obstruction, and the patient was ruled out for myocardial infarction. We recently reported that ST-segment elevation myocardial infarction (STEMI) in the intensive care unit (ICU) setting is a common electrocardiographic reading, both by standard interpretation software and by expert evaluation.2 Over a 15-month study period, this electrocardiogram (ECG) diagnosis was found in 67 of 2243 (2.99%) ICU patients who had an ECG performed. Eighty-five percent of the patients, however, were definitely ruled out for STEMI, indicating the highly nonspecific nature of this finding in the ICU. The causes
Figure Electrocardiograms (ECGs) of 2 intubated intensive care unit patients showing ST-segment elevations. Computer interpretations were moved to the ECGs. (A) A 62-year-old woman with respiratory failure and septic shock. Emergent cardiac catheterization showed no coronary occlusion, and the patient was ruled out for ST-segment elevation myocardial infarction. (B) A 60-year-old man with multilobar pneumonia and sepsis. Emergent bedside echocardiogram revealed normal left ventricular function without regional wall motion abnormality. The patient was ruled out for myocardial infarction. MI ¼ myocardial infarction. 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
e18 of ST-segment elevation were diverse and included acute brain injury, critical respiratory conditions, hyperkalemia, acute abdomen, sepsis, artifact, and, as in the case by Rechenmacher et al,1 pericardial irritation. The Figure illustrates 2 recent cases from our ICU in which the ECG suggested STEMI, but the patients were ruled out for myocardial infarction. Numerous conditions can mimic STEMI in the ECG.3 Based on our study in ICU patients2 and several recent case reports and case series, including the one by Rechenmacher et al,1,4,5 physicians caring for critically ill patients should be aware of the nonspecific nature of STEMI ECG in the ICU. In non-ICU patients who present with chest pain and ST-segment elevation, emergent cardiac catheterization and immediate reperfusion is standard of care. In intubated and sedated ICU patients, however, where history is usually unobtainable and cardiac catheterization may carry a higher risk, treatment decisions should be based on a more careful clinical risk assessment, possibly combined with the use of a bedside echocardiogram.6
The American Journal of Medicine, Vol 127, No 2, February 2014 Laszlo Littmann, MD, PhD Department of Internal Medicine Carolinas Medical Center Charlotte, NC
http://dx.doi.org/10.1016/j.amjmed.2013.08.019
References 1. Rechenmacher S, Jurewitz D, Southard J, Amsterdam E. Barking up the wrong tree: regional pericarditis mimicking STEMI. Am J Med. 2013;126:679-681. 2. Rennyson SL, Hunt J, Haley MW, et al. Electrocardiographic ST-segment elevation myocardial infarction in critically ill patients: an observational cohort analysis. Crit Care Med. 2010;38:2304-2309. 3. Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med. 2003;349: 2128-2135. 4. Littmann L, Monroe MH. The “spiked helmet” sign: a new electrocardiographic marker of critical illness and high risk of death. Mayo Clin Proc. 2011;86:1245-1246. 5. Chaudhry M, Omar Z, Latif F. Tombstone ST elevations: . not necessarily a harbinger of doom! Am J Med. 2013;126:e5-e6. 6. Poelaert J. Use of ultrasound in the ICU. Best Pract Res Clin Anaesthesiol. 2009;23:249-261.
Electrocardiographic STEMI: A Common but Nonspecific Finding in the ICU To the Editor: Rechenmacher et al1 describe an intubated trauma patient who was noted to have ST-segment elevation in the inferolateral leads. Emergent cardiac catheterization revealed no Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of the manuscript.
coronary obstruction, and the patient was ruled out for myocardial infarction. We recently reported that ST-segment elevation myocardial infarction (STEMI) in the intensive care unit (ICU) setting is a common electrocardiographic reading, both by standard interpretation software and by expert evaluation.2 Over a 15-month study period, this electrocardiogram (ECG) diagnosis was found in 67 of 2243 (2.99%) ICU patients who had an ECG performed. Eighty-five percent of the patients, however, were definitely ruled out for STEMI, indicating the highly nonspecific nature of this finding in the ICU. The causes
Figure Electrocardiograms (ECGs) of 2 intubated intensive care unit patients showing ST-segment elevations. Computer interpretations were moved to the ECGs. (A) A 62-year-old woman with respiratory failure and septic shock. Emergent cardiac catheterization showed no coronary occlusion, and the patient was ruled out for ST-segment elevation myocardial infarction. (B) A 60-year-old man with multilobar pneumonia and sepsis. Emergent bedside echocardiogram revealed normal left ventricular function without regional wall motion abnormality. The patient was ruled out for myocardial infarction. MI ¼ myocardial infarction. 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
e18 of ST-segment elevation were diverse and included acute brain injury, critical respiratory conditions, hyperkalemia, acute abdomen, sepsis, artifact, and, as in the case by Rechenmacher et al,1 pericardial irritation. The Figure illustrates 2 recent cases from our ICU in which the ECG suggested STEMI, but the patients were ruled out for myocardial infarction. Numerous conditions can mimic STEMI in the ECG.3 Based on our study in ICU patients2 and several recent case reports and case series, including the one by Rechenmacher et al,1,4,5 physicians caring for critically ill patients should be aware of the nonspecific nature of STEMI ECG in the ICU. In non-ICU patients who present with chest pain and ST-segment elevation, emergent cardiac catheterization and immediate reperfusion is standard of care. In intubated and sedated ICU patients, however, where history is usually unobtainable and cardiac catheterization may carry a higher risk, treatment decisions should be based on a more careful clinical risk assessment, possibly combined with the use of a bedside echocardiogram.6
The American Journal of Medicine, Vol 127, No 2, February 2014 Laszlo Littmann, MD, PhD Department of Internal Medicine Carolinas Medical Center Charlotte, NC
http://dx.doi.org/10.1016/j.amjmed.2013.08.019
References 1. Rechenmacher S, Jurewitz D, Southard J, Amsterdam E. Barking up the wrong tree: regional pericarditis mimicking STEMI. Am J Med. 2013;126:679-681. 2. Rennyson SL, Hunt J, Haley MW, et al. Electrocardiographic ST-segment elevation myocardial infarction in critically ill patients: an observational cohort analysis. Crit Care Med. 2010;38:2304-2309. 3. Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med. 2003;349: 2128-2135. 4. Littmann L, Monroe MH. The “spiked helmet” sign: a new electrocardiographic marker of critical illness and high risk of death. Mayo Clin Proc. 2011;86:1245-1246. 5. Chaudhry M, Omar Z, Latif F. Tombstone ST elevations: . not necessarily a harbinger of doom! Am J Med. 2013;126:e5-e6. 6. Poelaert J. Use of ultrasound in the ICU. Best Pract Res Clin Anaesthesiol. 2009;23:249-261.