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22 May 2017 : Case report  USA

Normalization of Diffuse ST-Depression with aVR Elevation After Rehydration in a Patient with Severe Aortic Stenosis

Unusual clinical course, Challenging differential diagnosis, Management of emergency care, Educational Purpose (only if useful for a systematic review or synthesis)

Sachin R. Patel1ABCDEF*, Vikas J Patel1ABDE, Brittany Clark2ACDE, George Rust3EF

DOI: 10.12659/AJCR.902510

Am J Case Rep 2017; 18:563-567

Abstract

BACKGROUND: Isolated ST elevation in lead aVR in combination with global ST depression with normalization after rehydration is a unique electrocardiographic pattern that is associated with a broad range of diagnoses. Its association with left main coronary artery disease and other acute coronary syndromes suggest the need for early and aggressive cardiac evaluation.

CASE REPORT: A 53-year-old man presented with altered mental status and loss of consciousness. He was unresponsive, hypotensive, tachycardiac, and diaphoretic. An initial ECG showed diffuse ST depression with isolated ST elevation in lead aVR, and initial troponin levels were negative. After rehydration, a repeat ECG showed sinus rhythm without ischemic changes. An emergent echocardiogram showed severe aortic stenosis and global hypokinesis. Repeat troponin results were elevated. The patient had 2 subsequent cardiac arrests. Emergent cardiac catheterization showed an occluded right coronary artery with collaterals and complete occlusion of the LAD. Urgent intra-aortic balloon pump was placed, followed by coronary artery bypass graft, aortic valve replacement, and a placement of a left ventricular assist device. Despite maximal hemodynamic support, the patient died after cardiac arrest due to massive myocardial infarction.

CONCLUSIONS: Normalization of diffuse ST depression with isolated aVR ST elevation on electrocardiography with improvement in clinical and hemodynamic status through fluid resuscitation can mask a stuttering myocardial infarction given its association with left main coronary artery disease and partial right coronary artery occlusion.

Keywords: Aortic Stenosis, Subvalvular, Coronary Artery Bypass, Coronary Artery Disease, Electrocardiography, Myocardial Infarction, Shock, Cardiogenic

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923