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Table of Contents
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 37-39  

Acute ST-segment elevation: Don't rush me to the catheter laboratory- please wait

Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar

Date of Submission12-Sep-2019
Date of Acceptance06-Nov-2019
Date of Web Publication23-Jan-2020

Correspondence Address:
Dr. Bassim Albizreh
Department of Cardiology, Heart Hospital, Hamad Medical Corporation, P. O. Box 3050, Doha
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Source of Support: None, Conflict of Interest: None


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We report a case of a young woman with no cardiac history who presented with out-of-hospital cardiac arrest and ST-segment elevation on the electrocardiogram. The cardiac arrest initially was suspected to be secondary to coronary artery disease. Further history was taken from a relative who said that the patient had a severe headache before the cardiac arrest. It was subsequenly found on computed tomography of the head that the patient had infratentorial subarachnoid hemorrhage and diffurse brain edema. The management of course was totally different from what was contemplated initially.
This case illustrates that ST-segment elevation can be caused by other conditions besides on occlusive thrombus in the coronary arteries.

Keywords: Hemorrhagic stroke, out-of-hospital cardiac arrest, ST-segment elevation

How to cite this article:
Albizreh B, Alibrahim M, Hamid T. Acute ST-segment elevation: Don't rush me to the catheter laboratory- please wait. Heart Views 2020;21:37-9

How to cite this URL:
Albizreh B, Alibrahim M, Hamid T. Acute ST-segment elevation: Don't rush me to the catheter laboratory- please wait. Heart Views [serial online] 2020 [cited 2023 Dec 2];21:37-9. Available from: https://www.heartviews.org/text.asp?2020/21/1/37/276537

   Introduction Top

Patients who survive out-of-hospital cardiac arrest (OHCA) usually have ischemic electrocardiogram (ECG) changes. ST-segment elevation (STE) in these patients usually indicates acute coronary syndrome as a likely cause. Acute ST-segment changes have been associated with other noncardiac causes including acute brain attack. Moreover, the associated acute ECG changes in case of acute subarachnoid hemorrhage could range from 27% to 100% of the cases.[1],[2]

   Case Presentation Top

We report a case of a 42-year-old married woman who was normally quite fit and well. She was an intermittent smoker with no other cardiovascular risk factors. While she was in a meeting, she collapsed to the floor, and bystanders started cardiopulmonary resuscitation (CPR) for 4–5 min.

On arrival of the ambulance, she was in cardiac arrest with pulseless electrical activity (PEA) rhythm. She was immediately intubated, and a mechanical chest compression device (LUCAS™ device) was commenced. She had return of spontaneous circulation (ROSC) after 15 min. A 12-lead ECG in the ambulance showed ST elevation [Figure 1]. Therefore, she was transferred directly to our heart institute for possible primary percutaneous coronary intervention (PPCI).
Figure 1: First electrocardiogram at the ambulance. Twelve-lead electrocardiogram showing ST-segment elevation in 1-aVL and ST depression in inferior leads

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On arrival to the hospital, she had further PEA arrest and CPR was commenced. There was no further detailed history of the event available at that time. After a brief CPR, she had ROSC, and the ECG confirmed ST-segment elevation in lateral leads with reciprocal changes in inferior leads [Figure 2].
Figure 2: Admission electrocardiogram. Twelve-lead electrocardiogram showing ST-segment elevation in 1-aVL (red arrows) and ST depression in inferior leads (blue arrows)

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Based on the available information including ECGs and cardiac arrest, a provisional diagnosis of acute STE myocardial infarction was made, and we started preparation for the PPCI procedure.

While a nasogastric tube was being inserted for medications, the husband and other family members arrived to the hospital. On discussion with the family and a brief relevant history, we found that the patient had asked for two tablets of pain killer for headache (acetaminophen) and then she collapsed.

Since the new information became available, we decided to do an urgent computed tomography (CT) head before the PPCI and withholding loading dose of antiplatelets. The CT head was arranged urgently, and the result came with an extensive supra- and infratentorial subarachnoid hemorrhage and diffuse brain edema [Figure 3]. Hence, the cardiac procedure was canceled, and the patient was immediately transferred to neurosurgical intensive care unit. The prognosis was grave and she did not survive this catastrophic event.
Figure 3: Computed tomography head. Computed tomography head showing extensive supra- and infratentorial subarachnoid hemorrhage and diffuse brain edema

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   Discussion Top

OHCA and ST-segment elevation on ECG is usually attributed to acute coronary syndrome and warrants urgent intervention. Usually, these patients are rushed to cath lab for urgent intervention and receive anticoagulation.

Hemorrhagic stroke can mimic morphological ECG changes in ACS with STE and can present with cardiac arrest. However, it has a totally different management and intervention. Antiplatelets and anticoagulation are absolute contraindications. Therefore, all additional information should be collected as much as possible, and a CT of brain should be considered before coronary intervention despite ST-segment elevation to avoid misdiagnosing another fatal disease with totally different management.

   Conclusion Top

The collection of all possible and relevant data is a must for proper diagnosis and management even if the initial diagnosis seemed clear at first glance. History and physical examination are musts despite advanced technology.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Chatterjee S. ECG changes in subarachnoid haemorrhage: A synopsis. Neth Heart J 2011;19:31-4.  Back to cited text no. 1
Zaroff JG, Rordorf GA, Newell JB, Ogilvy CS, Levinson JR. Cardiac outcome in patients with subarachnoid hemorrhage and electrocardiographic abnormalities. Neurosurgery 1999;44:34-9.  Back to cited text no. 2


  [Figure 1], [Figure 2], [Figure 3]


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