CASE REPORT


https://doi.org/10.5005/njem-11015-0019
National Journal of Emergency Medicine
Volume 1 | Issue 3 | Year 2023

Acute Pancreatitis Masquerading as ST-elevation Myocardial Infarction (STEMI)


Moin Pandith1https://orcid.org/0009-0003-9359-9242, Kushagra Mathur2https://orcid.org/0000-0002-7190-4416, Shafat Kenu3

1,2Department of Emergency Medicine, Paras Health, Srinagar, Jammu and Kashmir, India

3Department of General Medicine, Darent Valley Hospital, Dartford, Kent, United Kingdom

Corresponding Author: Moin Pandith, Department of Emergency Medicine, Paras Health, Srinagar, Jammu and Kashmir, India, Phone: +91 9910252416, e-mail: pandithmoin@gmail.com

How to cite this article: Pandith M, Mathur K, Kenu S. Acute Pancreatitis Masquerading as ST-elevation Myocardial Infarction (STEMI). Natl J Emerg Med 2023;1(3):77–79.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written Informed consent of the patient for the publication and no patient identifiers were used.

Received on: 30 November 2023; Accepted on: 20 December 2023; Published on: 25 January 2024

ABSTRACT

Introduction: Various non-cardiac conditions had been known to mimic electrocardiographic changes seen in acute myocardial Ischaemia or infarction. However, the electrocardiographic changes mimicking ST-elevation myocardial ischaemia (STEMI) in acute pancreatitis (AP) have been occasionally reported and is rare.

Case description: A 63-year-old male with no comorbidities or past medical illness presented to the emergency department (ED) with complaints of sudden onset of severe epigastric and retrosternal chest pain. In the ED, vitals were stable. ECG revealed ST-elevation in leads II, III, and aVF consistent with acute inferior wall MI. Bedside 2D electrocardiography was unremarkable. A point of care troponin-T test was done which came out to be negative. Laboratory workup revealed high levels of serum amylase (353 U/L) and serum lipase (1681 U/L) consistent with AP. Further, abdominal CT scan was done which confirmed changes consistent with acute inflammatory non-necrotising pancreatitis, thus confirming the diagnosis. Cardiac marker tests were negative and the patient was managed conservatively and discharged after 2 days in a stable condition with follow-up advice from gastroenterology team.

Discussion: A variety of non-cardiac abdominal pathologies like AP can mimic electrocardiographic findings suggestive of acute myocardial ischaemia. However, even with high sensitivity, ECG can have false-positive ST-T changes. It mandates a thorough history, clinical examination, and comprehensive investigation to establish a diagnosis and make a proper disposal from ED.

Keywords: Acute chest pain, Acute MI, Acute pancreatitis, Case report, Chest pain, STEMI.

INTRODUCTION

Acute pancreatitis (AP) is a common, inflammatory condition, associated with the gastrointestinal and hepatobiliary system and the most common cause of hospitalisation due to gastrointestinal illness in the United States with approximately 300,000 patients admitted to the ED annually.1 There are several causes which lead to AP: alcoholism and gall bladder stones being the commonest, both of which were not a risk factor in our case. Acute pancreatitis has a typical presentation of pain, which may vary, but has been described characteristically has a ‘sharp, epigastric, radiating to left back’.2 Pancreatitis is diagnosed by a combination of any 2 out of the following:3 Characteristic pain, laboratory findings consistent with AP, that is, raised lipase and amylase and radiological features suggestive of AP. These diagnostic criteria, along with several bedside and convenient prognostic scores help the physicians all over the world to treat the condition easily.

On the other side, a myocardial infarction is characterised by the death of a heart tissue or part of the muscle caused by decreased blood supply. It is one of the most common causes of death worldwide.3 It is characterised clinically by a crushing chest pain at the centre of the chest, radiating to left arm and jaw, seen as the ‘Levine sign’.4 The evidence of muscle death is quickly screening by an electrocardiography (ECG) which is a cost-effective, easy, sensitive and quick tool to look for a number of cardiac or related illnesses. The presence of an ST-elevation on an ECG is considered an evidence of muscle death.5,6

Both the conditions are life-threatening and require a holistic approach in the emergency department for early diagnosis, immediate management, and proper disposition.

CASE DESCRIPTION

A 63-year-old male presented to the emergency department during an evening shift with the presenting complaints of chest pain and discomfort that started 1 hour prior to his arrival to the ED. The pain was a sudden onset, severe in intensity, and more in the left lower part of the chest and also in epigastrium. He had no comorbidities, risk factors for coronary artery disease and pancreatitis as well. He had no remarkable past medical illness or similar episodes.

A bedside ECG was done at the time of arrival showed ST-segment elevation in leads II, III, and aVF as shown in Figure 1, changes are consistent with acute inferior wall MI.

Fig. 1: ECG showing ST-segment elevation in leads II, III, and aVF

The blood sampling was quickly performed, and routine investigations along with the serological quantitative testing for cardiac markers troponin I and CK-MB and pancreatic markers—amylase and lipase were sent.

A bedside qualitative test for the presence or absence of high levels of troponin-T in the blood was also performed which came out to be negative after 20 minutes.7 A repeat testing and serial cardiac marker tests were done to rule out any false-negative results; however, a repeat testing also showed a negative result. This meant that the test serum did not have the troponin-T concentration above the cut-off range. This was further confirmed by the laboratory results which too showed the troponin levels within the normal range. A bedside 2D ECHO was performed meanwhile to look for any wall motion abnormalities; however, the wall functions along with the EF were found to the normal. The patient was admitted for further evaluation, serial cardiac markers, and imaging in cardiology.

An abdominal CT scan was advised to look for abdominal causes of chest pain. The findings of the CT scan are shown in Figure 2. These were suggestive of acute inflammatory, non-necrotising pancreatitis. The laboratory results also showed high levels of serum amylase and lipase with their values as 353 (upper normal 100 U/L) and 1681 (upper normal 80 U/L), respectively, thus confirming the diagnosis of AP.

Figs 2A and B: Computed tomographic image of the abdomen showing bulky proximal body and tail of pancreas with peripancreatic fat stranding

After being moved under the care of gastroenterologist, the patient was treated conservatively and discharged in a stable condition with follow-up advice.

DISCUSSION

Electrocardiography is used as a quick, cost-effective and screening tool for several arrhythmia and structural disorders related to the heart. However, even with high sensitivity, it is bound to have false-positives results and is associated with a false-positive ST-T-related changes for a majority of diseases, such as pulmonary embolism, hyperkalaemia, subarachnoid haemorrhage and gastrointestinal conditions, such as AP and hiatus hernia.8 Therefore, it mandates a holistic approach by a physician of the emergency department to establish a cardiac cause or to rule out non-cardiac pathology for ST-T changes in the ECG and thus avoid unnecessary invasive procedures like cardiac catheterisation and for an appropriate disposition.

An article published in 2018 by Akanksha et al. also reported several patients diagnosed with AP, presenting with ST-elevation MI with ECG showing sinus bradycardia at 53 beats per minute, peaked T waves, 1 mm ST-segment elevation in leads II, III, and aVF, and 2 mm ST-elevation in V3.9 The patient also had raised lipase at a level of 25,304 IU and CT changes suggestive of pancreatitis and negative Trop-I.9

Another case report published in 2019 by Yu ES et al. highlighted a case which presented with symptoms suggestive of a heart attack but was found to have a normal coronary angiography results. He also developed left hemiplegia with radiological features suggestive of a diffused embolic stroke, but the cause of chest pain was found to be AP.10 They have very aptly used the phrase ‘appearance can be deceptive’ while describing the condition.

ORCID

Moin Pandith https://orcid.org/0009-0003-9359-9242

Kushagra Mathur https://orcid.org/0000-0002-7190-4416

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10. Yu ES, Lange JJ, Broor A, et al. Acute pancreatitis masquerading as inferior wall myocardial infarction: A review. Case Rep Gastroenterol 2019;13(2):321–335.DOI: 0.1159/000501197.

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