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Critical Care Medicine

A Peculiar ST Elevation Mimicking STEMI

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JAMA Internal Medicine

Published Online: December 27, 2022

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Jose Victor Jimenez, MD¹;

Soumya Banna, MD¹;

Nihar Desai, MD, MPH^2,3

Author Affiliations

¹Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
²Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
³Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut

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A patient in their 60s presented to the emergency department with a 2-week history of shortness of breath and back pain exacerbated that morning. The medical history was noteworthy for a remote history of cervical cancer. The patient was recently found to have a vesicovaginal fistula and metastatic lesions in the liver and lungs. Percutaneous bilateral nephrostomies were placed weeks before presentation. The patient also had a history of 40 pack-years of smoking but no known cardiovascular disease. On admission, blood pressure was 105/65 mm Hg, heart rate was 94 beats per minute, and respiratory rate was 16 breaths per minute. Jugular veins were mildly elevated, and cardiac examination was notable for a gallop and a soft systolic ejection murmur. Lung examination demonstrated basilar crackles, and there was grade 2 and higher lower-extremity edema. A 12-lead electrocardiogram (ECG) was performed on arrival (Figure).

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The ST elevation’s peculiar morphology is known as the spiked helmet sign (SHS) due to its resemblance to the military helmet, the Pickelhaube.¹ It is characterized by an upward shift preceding the QRS complex, which has a sharp R wave followed by a convex ST elevation.²

The spiked morphology is given by the QRS complexes buried in the dome-shaped pseudo–ST elevation. This STEMI mimic is characterized by an upsloping shift preceding the QRS complex, which appears to align with the ST elevation. In the present case, the upsloping shift was observed in V₄ through V₆ and the convex dome-shaped pseudo–ST elevation in the inferior leads and from V₄ through V₆.

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Article Information

Corresponding Author: Jose Victor Jimenez, MD, Department of Internal Medicine, Yale New Haven Hospital, 20 York St, New Haven, CT 06510 (josevictor.jimenezceja@yale.edu).

Published Online: December 27, 2022. doi:10.1001/jamainternmed.2022.5070

Conflict of Interest Disclosures: Dr Desai reported grants from Amgen, AstraZeneca, Boehringer Ingelheim, Cytokinetics, Novartis, and Vifor, as well as personal fees from Bayer, Bristol Myers Squibb, and scPharmaceuticals outside the submitted work. No other disclosures were reported.

References

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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.