Typical chest pain and precordial leads ST-elevation in patients with pacemakers – are we always looking at an acute myocardial infarction?

Marina M Ostojić; Tatjana S Potpara; Marija M Polovina; Mladen M Ostojić; Miodrag C Ostojić

doi:10.2298/3406

Marina M Ostojić Clinic of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
Tatjana S Potpara Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia Faculty of Medicine University of Belgrade, Serbia
Marija M Polovina Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
Mladen M Ostojić Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
Miodrag C Ostojić Faculty of Medicine University of Belgrade, Serbia

DOI: https://doi.org/10.2298/3406

Keywords: pacemaker, artificial, myocardial infarction, pericarditis, heart conduction system, catheter ablation, diagnosis, differential,

Abstract

Introduction. Electrocardiographic (ECG) diagnosis of acute myocardial infarction (AMI) in patients with paced rhythm is difficult. Sgarbossa’s criteria represent helpful diagnostic ECG tool. Case report. A 57-year-old female patient with paroxysmal atrial fibrillation and a permanent pacemaker presented in the Emergency Department with prolonged typical chest pain and ECG recording suggestive for AMI. Documented ECG changes correspond to the first Sgarbossa’s criterion for AMI in patients with dual pacemakers (ST-segment elevation of ≥ 5 mm in the presence of the negative QRS complex). The patient was sent to catheterization lab where coronary angiogram reveled normal findings. ECG changes occurred due to pericardial reaction following two interventions: pacemaker implantation a month before and radiofrequency catheter ablation of AV junction two weeks before presentation in Emergency Department. Conclusion. This case report points out to the limitations of proposed criteria that aid in the recognition of AMI in patients with underlying paced rhythm and possible cause(s) of transient electrocardiographic abnormalities

References

Sgarbossa EB, Pinski SL, Gates KB, Wagner GS. Early electrocar-diographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. Am J Cardiol 1996; 77(5): 423−4.

Kochiadakis GE, Kaleboubas MD, Igoumenidis NE, Skalidis EI, Vardas PE. Electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. PACE 2001; 24(8): 1289−90.

Karumbaiah K, Omar B. ST-elevation myocardial infarction in the presence of biventricular paced rhythm. J Emerg Med 2013; 45(2): 35−40.

Kautzner J, Bytesník J. Recurrent pericardial chest pain: a case of late right ventricular perforation after implantation of a trans-venous active-fixation ICD lead. PACE 2001; 24(1): 116−8.

Chauhan A, Grace AA, Newell SA, Stone DL, Shapiro LM, Schofield PM, et al. Early complications after dual chamber ver-sus single chamber pacemaker implantation. PACE 1994; 17(11 Pt 2): 2012−5.

Barold SS, Center S. Electrographic diagnosis of perforation of the heart by pacing catheter electrode. Am J Cardiol 1969; 24(2): 274−8.

Hindricks G. The Multicentre European Radiofrequency Survey (MERFS): complications of radiofrequency catheter ablation of arrhythmias. The Multicentre European Radiofrequency Survey (MERFS) investigators of the Working Group on Ar-rhythmias of the European Society. Eur Heart J 1993; 14(12): 1644−53.

Marshall HJ, Harris ZI, Griffith MJ, Gammage MD. Atrioven-tricular nodal ablation and implantation of mode switching dual chamber pacemakers: effective treatment for drug refrac-tory paroxysmal atrial fibrillation. Heart 1998; 79(6): 543−7.