Enrique Ostrzega (University of Southern California, Los Angeles, USA) and colleagues report in in JACC: Case Reports that using applied abdominal pressure relived the symptoms of an apparent sudden-onset ST-segment elevation myocardial infarction (STEMI) in a patient with severe gastrointestinal distention.
Ostrzega et al explain that a previously healthy 41-year-old male with three weeks of lower extremity swelling, fatigue and shortness of breath was admitted to hospital. He was taken to the intensive care unit (ICU) and later diagnosed with metastatic Hodgkin lymphoma. They add that while under sedation on a ventilator in the ICU, the patient’s cardiac monitor displayed sudden onset of STEMI. This prompted the treating clinicians to call for an emergent cardiology consult.
According to the authors, the patient’s physical examination showed significant abdominal distention. When an ultrasound probe was placed on the patient’s upper abdomen, the previously noted ST-segment elevations abruptly resolved on the cardiac monitor. These dynamic changes were confirmed with an ECG. There was immediate resolution of the ST-segment elevation when gentle palpation of the abdomen was performed. The consulting cardiology team suspected the cause may be related to the patient’s abdominal distention and performed an abdominal X-ray which revealed significant gastric distention. After a nasogastric tube was placed for gastric decompression, an ECG confirmed resolution of ST-segment elevations with no further documented ST-segment abnormalities or evidence of cardiac dysfunction.
Ostrzega comments: “It is important to be aware that, while rare, acute gastrointestinal distention can cause ST-segment changes on an ECG. Clinicians must distinguish these cases from true heart attacks to prevent unnecessary treatment and invasive procedures whenever possible.” He and his colleagues note in the report that when presented with an atypical case of ST-segment elevation on ECG, thorough examination and history are vital as other disorders can mimic a STEMI pattern on ECG. Some non-cardiac causes of ST-segment elevation include pancreatitis, community-acquired pneumonia and intracranial bleeding.
In most previously reported cases of gastrointestinal distention causing a STEMI pattern on ECG, coronary angiography confirmed no evidence of obstructive coronary artery disease, and in all reported cases it improved with management and resolution of the underlying gastrointestinal issue.