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(Circulation. 2003;108:e165.)
© 2003 American Heart Association, Inc.

Images in Cardiovascular Medicine

ST-Segment Elevation in an Unresponsive Patient

Glenn A. Hirsch, MD; Alan W. Heldman, MD; Ilan S. Wittstein, MD; Steven P. Schulman, MD; Gary Gerstenblith, MD

From the Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Md (G.A.H., A.W.H., I.S.W., S.P.S., G.G.), and the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md (G.A.H.).

Correspondence to Glenn A. Hirsch, MD, NIH/NHLBI, 10 Center Drive, MSC-1061, Building 10, Room B1D-416, Bethesda, MD 20892-1061. E-mail ghirsch{at}jhmi.edu

A distressed woman hailed a car for assistance several blocks from our institution. Upon arrival at the Emergency Department, she was unresponsive. Telemetry demonstrated ventricular fibrillation, and she was defibrillated to sinus rhythm with ECG, as shown in Figure 1. She was taken for emergent cardiac catheterization with a heart rate of 117 bpm and blood pressure of 95/55 mm Hg. Coronary angiography revealed no stenosis or flow abnormalities. During catheterization, ST-segment elevation resolved and recurred several times (Figure 2). Reinjection of the left coronary artery showed no change in diameter or TIMI (thrombolysis in myocardial infarction) flow during the periods of extreme elevation and near-normalization (Figure 3). Echocardiography showed anteroapical hypokinesis with a left ventricular ejection fraction of 0.25. She remained hypotensive, and an intra-aortic balloon pump was inserted. Cardiac enzymes were elevated, with a creatine kinase level of 1445 (24 to 170 IU/L), creatine kinase-MB of 177 (0 to 7 µg/L), and troponin I of 1.76 (0.3 to 0.5 ng/mL). The patient remained unresponsive. Computed tomography of the brain showed diffuse subarachnoid hemorrhage and cerebral edema (Figure 4). Further neurological testing showed brain death.

View larger version (132K): [in this window] [in a new window]   Figure 1. ECG obtained immediately after defibrillation demonstrates sinus tachycardia with anterolateral ST-segment elevation, inferior ST-segment depression, and a prolonged QT interval.

View larger version (23K): [in this window] [in a new window]   Figure 2. Dynamic ST-segment changes occurred over several minutes during cardiac catheterization. (Tracing shown was recorded from the same precordial lead.)

View larger version (158K): [in this window] [in a new window]   Figure 3. No coronary stenosis or vasospasm was present during coronary angiography.

View larger version (115K): [in this window] [in a new window]   Figure 4. A, Computed tomography of the brain revealed diffuse subarachnoid hemorrhage (arrows) and cerebral edema compared with previous head CT from the same patient (B).

This case demonstrates an electrocardiographic current of injury and serum evidence of myocardial necrosis despite angiographically normal coronary blood flow in the setting of subarachnoid hemorrhage. One important factor contributing to myocardial injury and left ventricular dysfunction in this setting is contraction band necrosis due to direct catecholamine toxicity.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hirsch, G. A. Articles by Gerstenblith, G. Search for Related Content PubMed PubMed Citation Articles by Hirsch, G. A. Articles by Gerstenblith, G.