A 64-year-old woman with a history of hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery disease, and smoking presented with two days of severe nausea, vomiting, and progressively worsening 8/10 dull “ripping” right upper quadrant/epigastric abdominal pain.
She appeared quite ill, but her vital signs were normal. Physical exam was remarkable for epigastric tenderness to palpation but no rebound. An ECG was obtained. (See figure.)
The ECG is notable for biphasic deep inverted T-waves in the anterior precordial leads and a very long QTc (580 ms). Physicians were concerned about acute coronary syndrome, and treated the patient with aspirin, heparin, and clopidogrel.
Fortunately, angiography revealed no LAD occlusion or stenosis and no ruptured plaque. Echocardiography showed mild decrease in systolic function and a septal wall motion abnormality. She was diagnosed with stress cardiomyopathy, which often presents with deep inverted T-waves and QT prolongation.
Upstream use (in the ED) of P2Y12 inhibitors before angiography may not have a benefit. Recent studies have shown this is definitely true with prasugrel and ticagrelor, and it is an open question for clopidogrel. The benefits of these medications for patients with ACS are significant, but a percentage of patients taken for emergent angiography will not have ACS. Treating all patients with a P2Y12 inhibitor increases adverse reactions. Acute pancreatitis is a relative contraindication to P2Y12 inhibitors because of the risk of hemorrhagic conversion. Treatment with clopidogrel may be delayed until after angiography in lower-risk patients if the time to cardiac catheterization is quick.
Find a complete discussion of this case and additional EKGs on March 5 in the EMN iPad app and on March 12 in the Spontaneous Circulation blog on www.EM-News.com, where the EMN app can also be downloaded for free.
Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.
Differential Diagnosis of deep inverted T-waves.
- Myocardial infarction (Wellens' reperfusion)
- Raised intracranial pressures
- Pulmonary embolism
- Left ventricular apical hypertrophy
- Stress cardiomyopathy (Takotsubo)
- Intracranial hemorrhage
- Post-tachycardia and post-pacemaker T-wave pattern
- Hypertrophic cardiomyopathy
- Bundle branch blocks and Wolff-Parkinson-White syndrome
- Idiopathic global T-wave inversion syndrome
- Normal finding in children
- Persistent juvenile T-wave pattern
- Apical hypertrophy (Yamaguchi syndrome; this variant of hypertrophic cardiomyopathy is characterized by myocardial hypertrophy localized to the apex of the left ventricle. Electrocardiogram shows giant inverted T-waves in the midprecordial leads. Echocardiography/magnetic resonance imaging or computed tomography scan can confirm the diagnosis.)