Hyperkalemia Mimicking Anteroseptal Myocardial Infarction

A rare feature that confuses clinicians

  • Raka Aldy Nugraha Universitas Indonesia Hospital https://orcid.org/0000-0003-4822-5412
  • Auliya Husen Universitas Indonesia Hospital
  • Hary Sakti Muliawan Department of Cardiology and Vascular Medicine, Universitas Indonesia Hospital https://orcid.org/0000-0003-2490-2511
  • Dian Zamroni Department of Cardiology and Vascular Medicine, Universitas Indonesia Hospital
Keywords: Hyperkalemia, non-ischemic ST elevation, arrhythmia

Abstract

Background: Hyperkalemia often results in cardiac emergency associated with fatal cardiac arrhythmias. However, the presence of ST segment elevation in hyperkalemia is rare and could potentially subject the patients to unnecessary risk of intervention. Most commonly, ST elevation in hyperkalemia presents in a down-sloping fashion compared to the typical convex or upsloping pattern in myocardial infarction. However, in some cases, the ST elevation morphology can be very identical and difficult to distinguish. Herein, we describe a hyperkalemic patient presenting with non-ischemic ST segment elevation that resolved spontaneously following therapy.

Case illustration: A 77-year-old, bed-ridden, inarticulate woman was admitted to emergency department with acute dyspnea perceived for 1.5 hours. The patient’s past clinical history included craniotomy for subdural hematoma, poorly controlled hypertension, hypertensive heart disease, rheumatoid arthritis, and dementia and was under candesartan, amlodipine, nebivolol, spironolactone, and atorvastatin treatment. The 12-lead electrocardiography (ECG) recording showed wide QRS complex with left bundle branch block pattern, slow atrial fibrillation with total atrioventricular block, ST segment elevation and Q wave in anteroseptal leads, and peaked T wave (Figure 1A). The pattern of ST elevation was indistinguishable from that of myocardial infarction which necessitated further laboratory confirmation. Laboratory results showed severe hyperkalemia (K+ 7.93 mmol/L) and normal troponin level (45.0 ng/L). The patient was given serial insulin-based therapy and calcium gluconate immediately. The follow-up ECG pictured normal sinus rhythm with no sign of bundle branch block, resolution of ST segment elevation, and reduction in T wave amplitude (Figure 1B). However, the reduction in potassium level was not significant and the patient also experienced an acute kidney injury. The patient was transferred to intensive care unit and was prepared for hemodialysis.

Conclusion: ST segment elevation is a rare feature of hyperkalemia that could mislead the patient’s treatment. Thorough ECG evaluation is the key to narrow down the differential diagnosis. Every deviant feature should not be interpreted separately. Laboratory tests could help confirm the diagnosis, particularly in patients with atypical presentation and could help avoid unnecessary risk of intervention.

Downloads

Download data is not yet available.

References

1. Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation [Internet]. 2015 Oct;95:148–201. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0300957215003299
2. Campese VM, Adenuga G. Electrophysiological and clinical consequences of hyperkalemia. Kidney Int Suppl [Internet]. 2016 Apr;6(1):16–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2157171616000046
3. Diercks DB, Shumaik GM, Harrigan RA, Brady WJ, Chan TC. Electrocardiographic manifestations: electrolyte abnormalities. J Emerg Med [Internet]. 2004 Aug;27(2):153–60. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0736467904001416
4. Wang K, Asinger RW, Marriott HJL. ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction. N Engl J Med [Internet]. 2003 Nov 27;349(22):2128–35. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMra022580
5. Heckle M, Agarwal M, Alsafwah S. ST Elevations in the Setting of Hyperkalemia. JAMA Intern Med [Internet]. 2018 Jan 1;178(1):133. Available from: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2017.6329
6. Peerbhai S, Masha L, DaSilva-DeAbreu A, Dhoble A. Hyperkalemia masked by pseudo-stemi infarct pattern and cardiac arrest. Int J Emerg Med [Internet]. 2017 Dec 26;10(1):3. Available from: https://intjem.biomedcentral.com/articles/10.1186/s12245-017-0132-0
7. Ziakas A, Basagiannis C, Stiliadis I. Pseudoinfarction pattern in a patient with hyperkalemia, diabetic ketoacidosis and normal coronary vessels: a case report. J Med Case Rep [Internet]. 2010 Dec 26;4(1):115. Available from: https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-4-115
8. Wray J, Yoo MJ, Bridwell RE, Tannenbaum L, Henderson J. ST-Segment Elevation in the Setting of Diabetic Ketoacidosis: Is It Acute Coronary Syndrome? Cureus [Internet]. 2020 Mar 25; Available from: https://www.cureus.com/articles/29251-st-segment-elevation-in-the-setting-of-diabetic-ketoacidosis-is-it-acute-coronary-syndrome
9. Sims DB, Sperling LS. ST-Segment Elevation Resulting From Hyperkalemia. Circulation [Internet]. 2005 May 17;111(19). Available from: https://www.ahajournals.org/doi/10.1161/01.CIR.0000165127.41028.D1
10. Weiss JN, Qu Z, Shivkumar K. Electrophysiology of Hypokalemia and Hyperkalemia. Circ Arrhythmia Electrophysiol [Internet]. 2017 Mar;10(3). Available from: https://www.ahajournals.org/doi/10.1161/CIRCEP.116.004667
11. Bellazzini MA, Meyer T. Pseudo-Myocardial Infarction in Diabetic Ketoacidosis with Hyperkalemia. J Emerg Med [Internet]. 2010 Oct;39(4):e139–41. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0736467907003551
12. Slovis C. ABC of clinical electrocardiography: Conditions not primarily affecting the heart. BMJ [Internet]. 2002 Jun 1;324(7349):1320–3. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.324.7349.1320
13. Pothiawala S. Hyperkalemia induced pseudo-myocardial infarction in septic shock. J Postgrad Med [Internet]. 2014;60(3):338. Available from: http://www.jpgmonline.com/text.asp?2014/60/3/338/138828
Published
2023-10-22
Views & Downloads
Abstract views: 1247   
Full text (PDF) downloads: 782   
How to Cite
Nugraha, R., Husen, A., Muliawan, H., & Zamroni, D. (2023). Hyperkalemia Mimicking Anteroseptal Myocardial Infarction. Indonesian Journal of Cardiology, 44(1), 28-32. https://doi.org/10.30701/ijc.1297