Electrocardiographic changes in a patient with pulmonary embolism and septic shock.
ABSTRACT Various electrocardiography (ECG) abnormalities have been reported in patients who present with pulmonary embolism (PE). Severe sepsis is also associated with ECG changes that may mimic ST elevation myocardial infarction. We report a case of an elderly patient with PE and septic shock associated with striking ECG changes.
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ABSTRACT: A 35-year-old man was referred to the emergency department after having a short syncopal episode while waiting for a Doppler scan of the lower extremities for a 4-week history of a painful right leg. He had no significant past medical history and was a non-smoker. On presentation he had severe chest pain and dyspnea associated with diaphoresis, and was hemodynamically unstable. His initial electrocardiogram (ECG) showed ST segment elevations in leads V(1-4), mimicking an anteroseptal myocardial infarction. However, the angiography showed the coronary arteries were normal and the right main pulmonary artery was partially occluded by large pulmonary emboli. The ECG changes were recorded in detail which also pointed to the diagnosis of pulmonary embolism (PE). This case shows how a PE can mimic an anteroseptal myocardial infarction on ECG, and the physiopathology of the ST elevation in PE was discussed.Circulation Journal 01/2009; 73(6):1157-9. · 3.58 Impact Factor
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ABSTRACT: Elevated cardiac biomarkers in conjunction with electrocardiographic (ECG) changes are valuable in diagnosing acute coronary syndrome (ACS). Elevated troponin I (TnI), while commonly seen in ACS, can also occur in entities such as sepsis and pulmonary thromboembolic disease. Raised TnI levels in patients with sepsis result from various mechanisms, including hypoperfusion or direct extension of infection to cardiac tissue, and can also serve as an important prognostic indicator. Electrocardiographic changes in sepsis are not as well described. Some of the ECG findings associated with septic shock include loss of QRS amplitude, increase in QTc interval, bundle branch blocks, and development of narrowed QRS intervals with deformed, positively deflected J waves (commonly known as Osborn waves). ST-segment elevations in sepsis are rare and have only previously been noted in a handful of case reports involving patients with septic shock. We present a case of a 59-year-old woman with ST-segment elevations and increased levels of cardiac troponin from Escherichia coli septic shock in the setting of normal coronary angiography.Postgraduate Medicine 04/2009; 121(2):102-5. · 1.97 Impact Factor
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ABSTRACT: Acute elevation of the ST segment in several ECG leads was observed in seven patients with bacterial shock during the course of therapy. Six patients had bacterial pneumonia, one had acute cholecystitis, and none had a previous history of heart disease. At the onset of the ST elevation, all patients were receiving dopamine infusion, which in four of them was inadvertently increased shortly before the ECG changes, the ST elevation was not associated with chest pain, pericardial friction rub, or acute changes in the heart rate, or arterial blood pressure. In four patients the maximum ST elevation was greater than or equal to 5 mm. In each instance the ST segment returned to the isoelectric line within 24 hours, and subsequent development of Q waves or changes in the QRS was not observed. Although the existence of an acute pericarditis or an acute myocarditis as possible causes of the ST elevation cannot be fully ruled out, the sudden onset, prominent magnitude, and brief duration of the ST elevation are perhaps more indicative of an acute ischemic event, possibly related to a transient coronary vasoconstriction induced by the dopamine infusion.Chest 05/1982; 81(4):444-8. · 5.85 Impact Factor
Print ISSN 1738-5520 / On-line ISSN 1738-5555
Copyright © 2011 The Korean Society of Cardiology
IMAGES IN CARDIOVASCULAR MEDICINE
Received: January 6, 2011 / Accepted: February 25, 2011
Correspondence: Antonios N Pavlidis, MD, Department of Cardiology, Asklepeion General Hospital, V. Pavlou 1 Street, 16673 Athens, Greece
Tel: 306947807977, Fax: 302106646902, E-mail: email@example.com
• The authors have no financial conflicts of interest.
cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licens-
es/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
A 92-year-old woman was admitted with acute dyspnea, al-
tered mental status and a 3-day history of fevers and rigors.
On arrival, she was febrile, hypotensive and tachycardic. Elec-
trocardiography (ECG) showed multifocal atrial tachycardia
and widespread concave ST segment elevation in the precor-
dial and lateral leads (Fig. 1). Bedside echocardiogram reve-
aled a large, free-floating, right atrial thrombus intermittently
prolapsing through the tricuspid valve into the right ventricle.
Right and left ventricular systolic functions were preserved
and no regional wall motion abnormalities (RWMA) were pre-
sent. Contrast-enhanced CT pulmonary angiogram demon-
strated multiple large bilateral pulmonary emboli. She was
successfully resuscitated with intravenous colloids, piperacil-
lin/tazobactam, antipyretics and unfractionated heparin in-
fusion. Repeat ECG obtained one hour later revealed persist-
ence tachyarrhythmia but spontaneous resolution of ST seg-
ment elevation (Fig. 2). At which point the patient had be-
came afebrile and normotensive, while echocardiographic
manifestations remained unchanged. Admission electrolytes
were normal and Troponin I peaked at 0.79 ng/dL. Blood and
urine cultures isolated a multisensitive strain of Escherichia
Several ECG changes have been identified in patients with
pulmonary embolism (PE).1) Precordial ST segment elevation
has been previously described in patients with extensive PE.2)3)
However, similar ECG manifestations have been described
in patients with severe sepsis and normal coronary arteries.4)5)
In our patient, despite the absence of RWMA and significant
enzyme increase, acute coronary syndrome, coronary vaso-
spasm and acute myocarditis constituted the differential di-
agnoses, as coronary angiography and endomyocardial bi-
opsy were not readily available.
1) Ryu HM, Lee JH, Kwon YS, et al. Electrocardiography patterns and
the role of the electrocardiography score for risk stratification in acute
pulmonary embolism. Korean Circ J 2010;40:499-506.
2) Goslar T, Podbregar M. Acute ECG ST-segment elevation mimicking
myocardial infarction in a patient with pulmonary embolism. Cardio-
vasc Ultrasound 2010;8:50.
3) Lin JF, Li YC, Yang PL. A case of massive pulmonary embolism with
ST elevation in leads V1-4. Circ J 2009;73:1157-9.
4) Martinez JD, Babu RV, Sharma G. Escherichia coli septic shock mas-
querading as ST-segment elevation myocardial infarction. Postgrad
5) Terradellas JB, Bellot JF, Sarís AB, Gil CL, Torrallardona AT, Garriga
JR. Acute and transient ST segment elevation during bacterial shock in
seven patients without apparent heart disease. Chest 1982;81:444-8.
Electrocardiographic Changes in a Patient
With Pulmonary Embolism and Septic Shock
Antonios N Pavlidis, MD1, Leonidas E Poulimenos, MD1, Antreas K Giannakopoulos, MD1,
Athanasios Tsoukas, MD1, Manolis S Kallistratos, MD1, and Athanasios J Manolis, MD1,2
1Department of Cardiology, Asklepeion General Hospital, Athens, Greece
2Emory University School of Medicine, Atlanta, USA
Various electrocardiography (ECG) abnormalities have been reported in patients who present with pulmonary embolism
(PE). Severe sepsis is also associated with ECG changes that may mimic ST elevation myocardial infarction. We report a case
of an elderly patient with PE and septic shock associated with striking ECG changes. (Korean Circ J 2011;41:692-693)
KEY WORDS: Pulmonary embolism; Electrocardiogram; Sepsis.
Antonios N Pavlidis, et al. 693