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ST-segment elevation in non-atherosclerotic coronaries: a brief overview

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Abstract

The most common, clinically significant cause of ST elevation is an angiographically demonstrable occlusive disease due to atherosclerotic changes in coronary artery. Often, a patient presenting with non-specific complaints and ST-segment elevation on the electrocardiogram, is sent for a cardiac catheterization only to see no luminal stenosis on the angiogram. This clinical review is intended to inform emergency medicine physicians and internists about the conditions in which ST-segment elevation is accompanied with no atherosclerotic lesion on coronary angiography. These situations make a diverse array of conditions ranging from anomalous coronaries to anatomically normal coronaries with varied degrees of myocardial injury. These conditions are briefly reviewed in this article.

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References

  1. Thygesen K, Alpert JS, White HD et al (2007) Universal definition of myocardial infarction. Circulation 116:2634–2653

    Article  PubMed  Google Scholar 

  2. Waller BF, Fry ET, Hermiller JB et al (1996) Nonatherosclerotic causes of coronary artery narrowing––Part I. Clin Cardiol 19:509–512

    Article  PubMed  CAS  Google Scholar 

  3. Alpert JS (1994) Myocardial infarction with angiographically normal coronary arteries [see comment]. Arch Intern Med 154:265–269

    Article  PubMed  CAS  Google Scholar 

  4. Ammann P, Marschall S, Kraus M et al (2000) Characteristics and prognosis of myocardial infarction in patients with normal coronary arteries. Chest 117:333–338

    Article  PubMed  CAS  Google Scholar 

  5. Surawicz B, Parikh SR (2002) Prevalence of male and female patterns of early ventricular repolarization in the normal ECG of males and females from childhood to old age. J Am Coll Cardiol 40:1870–1876

    Article  PubMed  Google Scholar 

  6. Klatsky AL, Oehm R, Cooper RA et al (2003) The early repolarization normal variant electrocardiogram: correlates and consequences. Am J Med 115:171–177

    Article  PubMed  Google Scholar 

  7. Gottschalk CW, Craige E (1956) A comparison of the precordial S–T and T waves in the electrocardiograms of 600 healthy young Negro and white adults. South Med J 49:453–457

    PubMed  CAS  Google Scholar 

  8. Marafioti V, Variola A (2004) Pseudoinfarction pattern by misplacement of electrocardiographic precordial leads. Am J Emerg Med 22:62–63

    Article  PubMed  Google Scholar 

  9. Van Gelder IC, Crijns HJ, Van der Laarse A et al (1991) Incidence and clinical significance of ST segment elevation after electrical cardioversion of atrial fibrillation and atrial flutter [see comment]. Am Heart J 121:51–56

    Article  PubMed  Google Scholar 

  10. Kok LC, Mitchell MA, Haines DE et al (2000) Transient ST elevation after transthoracic cardioversion in patients with hemodynamically unstable ventricular tachyarrhythmia. Am J Cardiol 85:878–881

    Article  PubMed  CAS  Google Scholar 

  11. Vikenes K, Omvik P, Farstad M et al (2000) Cardiac biochemical markers after cardioversion of atrial fibrillation or atrial flutter. Am Heart J 140:690–696

    Article  PubMed  CAS  Google Scholar 

  12. Levin DC, Fellows KE, Abrams HL (1978) Hemodynamically significant primary anomalies of the coronary arteries. Angiographic aspects. Circulation 58:25–34

    PubMed  CAS  Google Scholar 

  13. Angelini P (2007) Coronary artery anomalies: an entity in search of an identity. Circulation 115:1296–1305

    PubMed  Google Scholar 

  14. Irvin RG (1982) The angiographic prevalence of myocardial bridging in man. Chest 81:198–202

    Article  PubMed  CAS  Google Scholar 

  15. Soran O, Pamir G, Erol C et al (2000) The incidence and significance of myocardial bridge in a prospectively defined population of patients undergoing coronary angiography for chest pain. Tokai J Exp Clin Med 25:57–60

    PubMed  CAS  Google Scholar 

  16. Alegria JR, Herrmann J, Holmes DR Jr et al (2005) Myocardial bridging. Eur Heart J 26:1159–1168

    Article  PubMed  Google Scholar 

  17. Kereiakes DJ, Topol EJ, George BS et al (1991) Myocardial infarction with minimal coronary atherosclerosis in the era of thrombolytic reperfusion. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. J Am Coll Cardiol 17:304–312

    Article  PubMed  CAS  Google Scholar 

  18. Maseri A, Severi S, Nes MD et al (1978) “Variant” angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. Pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients. Am J Cardiol 42:1019–1035

    Article  PubMed  CAS  Google Scholar 

  19. Ginsburg R, Schroeder JS, Harrison DC (1982) Coronary artery spasm––pathophysiology, clinical presentations, diagnostic approaches and rational treatment. West J Med 136:398–410

    PubMed  CAS  Google Scholar 

  20. El Menyar AA (2006) Drug-induced myocardial infarction secondary to coronary artery spasm in teenagers and young adults. J Postgrad Med 52:51–56

    PubMed  Google Scholar 

  21. Stern S, Bayes de Luna A (2009) Coronary artery spasm: a 2009 update. Circulation 119:2531–2534

    Article  PubMed  Google Scholar 

  22. Sztajzel J, Mach F, Righetti A (2000) Role of the vascular endothelium in patients with angina pectoris or acute myocardial infarction with normal coronary arteries. Postgrad Med J 76:16–21

    Article  PubMed  CAS  Google Scholar 

  23. Tun A, Khan IA (2001) Myocardial infarction with normal coronary arteries: the pathologic and clinical perspectives. Angiology 52:299–304

    Article  PubMed  CAS  Google Scholar 

  24. Korkmaz C, Cansu DU, Kaşifoğlu T (2007) Myocardial infarction in young patients (< or = 35 years of age) with systemic lupus erythematosus: a case report and clinical analysis of the literature. Lupus 16:289–297

    Article  PubMed  CAS  Google Scholar 

  25. Cocco G, Gasparyan AY (2010) Myocardial ischemia in Wegener’s granulomatosis: coronary atherosclerosis versus vasculitis. Open Cardiovasc Med J 4:57–62

    PubMed  Google Scholar 

  26. Sgarbossa EB, Pinski SL, Barbagelata A et al (1996) Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators [see comment] [erratum appears in N Engl J Med 1996 Apr 4;334(14):931]. N Engl J Med 334:481–487

    Article  PubMed  CAS  Google Scholar 

  27. Tabas JA, Rodriguez RM, Seligman HK et al (2008) Electrocardiographic criteria for detecting acute myocardial infarction in patients with left bundle branch block: a meta-analysis. Ann Emerg Med 52:329–336 e321

    Google Scholar 

  28. Fahy GJ, Pinski SL, Miller DP et al (1996) Natural history of isolated bundle branch block. Am J Cardiol 77:1185–1190

    Article  PubMed  CAS  Google Scholar 

  29. Guler N, Eryonucu B, Bilge M et al (2001) Wolff-Parkinson-White syndrome mimicking acute anterior myocardial infarction in a young male patient––a case report. Angiology 52:293–295

    Article  PubMed  CAS  Google Scholar 

  30. Goldberger AL (1980) Pseudo-infarct patterns in the Wolff-Parkinson-White syndrome: importance of Q wave-T wave vector discordance. J Electrocardiol 13:115–118

    Article  PubMed  CAS  Google Scholar 

  31. Khan IA, Shaw IS (2000) Pseudo ventricular hypertrophy and pseudo myocardial infarction in Wolff-Parkinson-White syndrome. Am J Emerg Med 18:807–809

    Article  PubMed  CAS  Google Scholar 

  32. Ginzton LE, Laks MM (1982) The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation 65:1004–1009

    PubMed  CAS  Google Scholar 

  33. Mahrholdt H, Goedecke C, Wagner A et al (2004) Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation 109:1250–1258

    Article  PubMed  Google Scholar 

  34. Hunt SA, Abraham WT, Chin MH et al (2009) 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol 53:e1–e90

    Article  PubMed  Google Scholar 

  35. Aziz KU, Patel N, Sadullah T et al (2010) Acute viral myocarditis: role of immunosuppression: a prospective randomised study. Cardiol Young 20:509–515

    Article  PubMed  Google Scholar 

  36. Sims DB, Sperling LS (2005) Images in cardiovascular medicine. ST-segment elevation resulting from hyperkalemia. Circulation 111:e295–e296

    Article  PubMed  Google Scholar 

  37. Wang K (2004) Images in clinical medicine. “Pseudoinfarction” pattern due to hyperkalemia. N Engl J Med 351:593

    Article  PubMed  CAS  Google Scholar 

  38. Brugada P, Brugada J (1992) Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report [see comment]. J Am Coll Cardiol 20:1391–1396

    Article  PubMed  CAS  Google Scholar 

  39. Ozeke O, Aras D, Deveci B et al (2006) Brugada-like early repolarization pattern misdiagnosed as acute anterior myocardial infarction in a patient with myocardial bridging of the left anterior descending artery. Mt Sinai J Med 73:627–630

    PubMed  Google Scholar 

  40. Lin JF, Li YC, Yang PL (2009) A case of massive pulmonary embolism with ST elevation in leads V1–4. Circ J 73:1157–1159

    Article  PubMed  Google Scholar 

  41. Sommargren CE, Zaroff JG, Banki N et al (2002) Electrocardiographic repolarization abnormalities in subarachnoid hemorrhage. J Electrocardiol 35(Suppl):257–262

    Article  PubMed  Google Scholar 

  42. Kawasaki T, Azuma A, Sawada T et al (2002) Electrocardiographic score as a predictor of mortality after subarachnoid hemorrhage. Circulation J 66:567–570

    Article  Google Scholar 

  43. Nakamura Y, Kaseno K, Kubo T (1989) Transient ST-segment elevation in subarachnoid hemorrhage. J Electrocardiol 22:133–137

    Article  PubMed  CAS  Google Scholar 

  44. Azzarelli S, Galassi AR, Amico F et al (2006) Clinical features of transient left ventricular apical ballooning. Am J Cardiol 98:1273–1276

    Article  PubMed  Google Scholar 

  45. Wittstein IS, Thiemann DR, Lima JAC et al (2005) Neurohumoral features of myocardial stunning due to sudden emotional stress [see comment]. N Engl J Med 352:539–548

    Article  PubMed  CAS  Google Scholar 

  46. Kurisu S, Sato H, Kawagoe T et al (2002) Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 143:448–455

    Article  PubMed  Google Scholar 

  47. Bhadani UK, Tripathi M, Sharma S et al (2006) Scorpion sting envenomation presenting with pulmonary edema in adults: a report of seven cases from Nepal. Indian J Med Sci 60:19–23

    Article  PubMed  Google Scholar 

  48. Bawaskar HS, Bawaskar PH (1994) Vasodilators: scorpion envenoming and the heart (an Indian experience). Toxicon 32:1031–1040

    Article  PubMed  CAS  Google Scholar 

  49. Bawaskar HS, Bawaskar PH (2003) Clinical profile of severe scorpion envenomation in children at rural setting. Indian Pediatr 40:1072–1075

    PubMed  Google Scholar 

  50. Engel J, Brady WJ, Mattu A et al (2002) Electrocardiographic ST segment elevation: Left ventricular aneurysm. Am J Emerg Med 20:238–242

    Article  PubMed  Google Scholar 

  51. Bourassa MG, Butnaru A, Lesperance J, Tardif JC (2003) Symptomatic myocardial bridges: overview of ischemic mechanisms and current diagnostic and treatment strategies. J Am Coll Cardiol 41(3):351–359

    Article  PubMed  Google Scholar 

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Acknowledgments

I thank all my co-authors for their invaluable efforts in success of this review.

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None.

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Authors and Affiliations

  1. Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA

    Subhash Chandra & Dipti Agarwal

  2. Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    Vikas Singh

  3. Department of Internal Medicine, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, USA

    Mahendra Nehra

  4. Department of Internal Medicine, Southern Illinois University, Springfield, IL, USA

    Nishit Singh

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  1. Subhash Chandra
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  2. Vikas Singh
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  3. Mahendra Nehra
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  4. Dipti Agarwal
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Correspondence to Subhash Chandra.

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Chandra, S., Singh, V., Nehra, M. et al. ST-segment elevation in non-atherosclerotic coronaries: a brief overview. Intern Emerg Med 6, 129–139 (2011). https://doi.org/10.1007/s11739-010-0491-5

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  • DOI: https://doi.org/10.1007/s11739-010-0491-5

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