Chest pain and ST elevation: not always ST-segment-elevation myocardial infarction

Our plain-English summary of Chest pain and ST elevation: not always ST-segment-elevation myocardial infarction, by S.A. Pyxaras, G. Lardieri, M. Milo, et al (Journal of Cardiovascular Medicine, 2010).

The study

• Authors: S.A. Pyxaras, G. Lardieri, M. Milo, G. Vitrella, G. Sinagra
• Journal: Journal of Cardiovascular Medicine
• Published: 2010;11(8):615-8
• Type of article: Case report
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

A 59-year-old male patient affected by pleural mesothelioma presented with chest pain and localized ST elevation in the electrocardiogram. Urgent coronary angiography excluded an acute coronary occlusion, whereas high-resolution computed tomography of the chest revealed tumor infiltration and associated acute inflammation of the pericardial sac. This case illustrates how initial clinical evaluation during emergency conditions could be misled by the time-effectiveness imperative in the primary percutaneous coronary intervention era. In conclusion, early valorization of clinical signs and noninvasive diagnostic elements may add accuracy in directing the postadmission patient course.

In plain English

This case report from Trieste, Italy, described a 59-year-old man with left-sided pleural mesothelioma. About six months earlier he had noticed increased shortness of breath. A CT scan then suggested mesothelioma, later confirmed by biopsy, and he was treated with pleurectomy, radiotherapy and chemotherapy. He had worked as a shipyard laborer for 10 years and later as a nurse. The article does not mention asbestos. He was admitted with chest pain, palpitations and shortness of breath. His electrocardiogram showed ST-segment elevation, so a heart attack was suspected. Emergency coronary angiography found no significant coronary artery disease, and his first troponin I test was within normal limits. Echocardiography showed a localized pericardial effusion. CT scanning showed the pleural mesothelioma had infiltrated the nearby pericardium, the sac around the heart. After treatment with aspirin and prednisone, his symptoms resolved rapidly. He remained free of symptoms and recurrences at mid-term follow-up. The authors concluded that other causes of ST-segment elevation should always be considered and not confused with heart attack. They also wrote that findings suggesting pericarditis, such as PR-segment depression, can also occur in heart attack, so coronary angiography remains indispensable.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 59-year-old man with biopsy-confirmed left-sided pleural mesothelioma, admitted to hospital in Trieste, Italy, with chest pain, palpitations and shortness of breath
• Exposure: The article reports that the patient had worked as a shipyard laborer for 10 years and later as a nurse. It does not mention asbestos or any fiber type. Treatments he had received for the mesothelioma were pleurectomy with decortication, radiotherapy, and chemotherapy with carboplatinum and pemetrexed.
• Main results:
  • About 6 months before admission the patient noticed increased shortness of breath. CT then suggested a left-sided pleural mesothelioma, which was later confirmed by biopsy and histological exam. The article does not give the biopsy date.
  • After electrical cardioversion, the patient's ECG showed diffuse ST-segment elevation with PR-segment depression. The figure legend describes this as consistent with pericarditis.
  • Emergency coronary angiography found no significant coronary artery disease in this patient.
  • The patient's first troponin I result was 0.03 mg/ml, which was within normal limits for the authors' laboratory.
  • Echocardiography showed normal heart wall motion and a localized lateral and inferior pericardial effusion, without signs of tamponade.
  • High-resolution CT showed the pleural mesothelioma infiltrating the contiguous pericardium. It also showed a pericardial effusion of 18 mm maximum thickness and multifocal mediastinal lymph node enlargement.
  • The patient was treated with aspirin and prednisone, and all his symptoms resolved rapidly.
  • The patient's C-reactive protein fell from 210 to 3.26 mg/dl by discharge, and his troponin I stayed within normal levels.
  • The patient remained free of symptoms and recurrences at mid-term follow-up. An echocardiogram 2 weeks after discharge showed no pericardial effusion.
• The authors' conclusion: The authors concluded that causes of ST-segment elevation other than heart attack should always be considered and not confused with acute myocardial infarction. In discussing this case, they also wrote that findings suggesting pericarditis do not reliably exclude a heart attack. In patients with prior chemotherapy or radiotherapy, Dressler's syndrome cannot be excluded at first, and PR-segment depression can also occur in acute myocardial infarction. For these reasons, they wrote, coronary angiography remains indispensable.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Inflammation, Pericardial.

Related studies

• Rare cause of myocardial infarction, stroke, and lung tumour — M. Medvegy, A. Szekula, et al. (2013)
• A 70-year-old woman with dyspnea and chest pain — A. Ganesh, M. Flores, et al. (2014)
• Pericardial mesothelioma presenting as a suspected ST-elevation myocardial infarction — A.S. Barroso, S. Leite, et al. (2017)
• Chest pain in asbestos-exposed individuals with benign pleural and parenchymal disease — S. Mukherjee, N. de Klerk, et al. (2000)
• Chest pain in asbestos and silica-exposed workers — E.K. Park, P.S. Thomas, et al. (2011)
• A retrospective study of chest pain in benign asbestos pleural disease — R.K. Allen, T. Cramond, et al. (2011)

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