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Acute Coronary Syndromes

Huge Diagnostic and Treatment Challenges—A Confusing Coexistence

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JAMA Internal Medicine

Published Online: September 12, 2022

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Wei Wei, MD, PhD¹;

Tong Liu, MD, PhD²

Author Affiliations

¹Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
²Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People’s Republic of China

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A patient in their 30s with no known medical history presented to the emergency department with 6 hours of vertigo, vomiting, dysarthria, and left-sided weakness. They denied any chest pain or shortness of breath. Vital signs were normal. A brain computed tomographic scan (CT) was consistent with a large infarction of the left cerebellar hemisphere and left pontine. An electrocardiogram (ECG) obtained on admission is shown in Figure, A. Subsequent investigation revealed a troponin T level of 1349 pg/mL (reference range, <14 pg/mL) and an N-terminal probrain natriuretic peptide level of 1674 pg/mL (reference range, <125 pg/mL). Test results for thrombophilia, vasculitis, and antiphospholipid syndrome were all negative. Echocardiogram showed regional wall-motion abnormalities of the left ventricle with a reduced ejection fraction of 36%. The patient was initially diagnosed with acute ischemic stroke and ST-segment elevation myocardial infarction (STEMI).

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Stroke-heart syndrome has been considered a perfect storm for patients with stroke, which could be classified into 5 categories (1) ischemic and nonischemic acute myocardial injury presenting with elevated troponin levels, which is usually asymptomatic; (2) acute myocardial infarction; (3) left ventricular dysfunction; (4) neurogenic sudden cardiac death; and (5) ECG changes.² It has been reported² that nearly 91% of patients with acute ischemic stroke (AIS) could present with new ECG abnormalities in unselected populations, and 32% for those without preexisting cardiac diseases. Various ECG changes may occur in the setting of AIS, including ST-segment elevation, ST-segment depression, unspecified ST-T changes, QT prolongation, T inversion, abnormal T-wave morphology, bundle branch block and pathologic Q waves, among which unspecified ST changes and ST depression represent the 2 most common types.³ To our knowledge, de Winter ECG pattern induced by SIHI has never been reported previously.

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Article Information

Corresponding Author: Tong Liu, MD, PhD, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, No. 23, Pingjiang Rd, Hexi District, Tianjin 300211, People’s Republic of China (liutong@tmu.edu.cn).

Published Online: September 12, 2022. doi:10.1001/jamainternmed.2022.3707

Conflict of Interest Disclosures: None reported.

Funding/Support: The work was funded by National Natural Science Foundation of China (81900301), Science and Technology Planning Project of Guangzhou (201904010451).

Role of the Funder/Sponsor: The National Natural Science Foundation of China had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Chuan-Hai Zhang, MD, from Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, and Nan Zhang, MD, from Second Hospital of Tianjin Medical University, for their helpful comments. They were not compensated.

References

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Sposato LA , Hilz MJ , Aspberg S , et al; World Stroke Organisation Brain & Heart Task Force. Post-stroke cardiovascular complications and neurogenic cardiac injury: JACC state-of-the-art review. J Am Coll Cardiol. 2020;76(23):2768-2785. doi:10.1016/j.jacc.2020.10.009 PubMed Google Scholar Crossref

Khechinashvili G , Asplund K . Electrocardiographic changes in patients with acute stroke: a systematic review. Cerebrovasc Dis. 2002;14(2):67-76. doi:10.1159/000064733 PubMed Google Scholar Crossref

Xu WW , Lu L , Jin MJ . de Winter electrocardiogram pattern-an unusual ST-segment elevation myocardial infarction equivalent pattern. JAMA Intern Med. 2019;179(11):1575-1577. doi:10.1001/jamainternmed.2019.4127 PubMed Google Scholar Crossref

García-Izquierdo E , Parra-Esteban C , Mirelis JG , Fernández-Lozano I . The de Winter ECG pattern in the absence of acute coronary artery occlusion. Can J Cardiol. 2018;34(2):209.e1-209.e3. doi:10.1016/j.cjca.2017.11.014 PubMed Google Scholar Crossref

Raja JM , Nanda A , Pour-Ghaz I , Khouzam RN . Is early invasive management as ST elevation myocardial infarction warranted in de Winter’s sign?-a “peak” into the widow-maker. Ann Transl Med. 2019;7(17):412. doi:10.21037/atm.2019.07.19 PubMed Google Scholar Crossref

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.