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Pavlidis, Poulimenos, Giannakopoulos, Tsoukas, Kallistratos, and Manolis: Electrocardiographic Changes in a Patient With Pulmonary Embolism and Septic Shock
Images in Cardiovascular Medicine
Korean Circulation Journal

Korean Circulation Journal 2011; 41(11): 692-693.

Published online: 29 November 2011

DOI: https://doi.org/10.4070/kcj.2011.41.11.692

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, Athanasios J Manolis, MD1, 2

1Department of Cardiology, Asklepeion General Hospital, Athens, Greece.

2Emory University School of Medicine, Atlanta, USA.

Correspondence: Antonios N Pavlidis, MD, Department of Cardiology, Asklepeion General Hospital, V. Pavlou 1 Street, 16673 Athens, Greece. Tel: 306947807977, Fax: 302106646902, antonispav@yahoo.com

Received 6 January 2011       Accepted 25 February 2011

Copyright © 2011 The Korean Society of Cardiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Pulmonary embolism, Electrocardiogram, Sepsis

A 92-year-old woman was admitted with acute dyspnea, altered mental status and a 3-day history of fevers and rigors. On arrival, she was febrile, hypotensive and tachycardic. Electrocardiography (ECG) showed multifocal atrial tachycardia and widespread concave ST segment elevation in the precordial and lateral leads (Fig. 1). Bedside echocardiogram revealed 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 present. Contrast-enhanced CT pulmonary angiogram demonstrated multiple large bilateral pulmonary emboli. She was successfully resuscitated with intravenous colloids, piperacillin/tazobactam, antipyretics and unfractionated heparin infusion. Repeat ECG obtained one hour later revealed persistence tachyarrhythmia but spontaneous resolution of ST segment elevation (Fig. 2). At which point the patient had became 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 Coli.
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 vasospasm and acute myocarditis constituted the differential diagnoses, as coronary angiography and endomyocardial biopsy were not readily available.

Figures and Tables

Fig. 1
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Fig. 2
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Notes

The authors have no financial conflicts of interest.

References

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. Cardiovasc 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. 73:1157–1159.
4. Martinez JD, Babu RV, Sharma G. Escherichia coli septic shock masquerading as ST-segment elevation myocardial infarction. Postgrad Med. 2009. 121:102–105.
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. 81:444–448.
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