Beware the normal angiogram
Editor – Pearson and Snelson presented an interesting case of a patient with purulent pericarditis complicated by septicaemia and acute renal failure (Clin Med February 2014 pp 88–89). The patient presented with left-sided chest pain and shortness of breath, and underwent emergency coronary angiography in view of pathological ST elevation on electrocardiography (ECG). However, the decision to perform emergency coronary angiography before other investigations warrants scrutiny. The ECG in fact showed global ST elevation, most marked in all the V leads but subtley present in the limb leads. Global ST elevation without reciprocal ST depression should always alert clinicians to the possibility of pericarditis rather than ST elevation myocardial infarction, and the immediate investigation of choice should be echocardiography since this will determine whether there is pericardial effusion and assess whether there is any regional wall motion abnormality that would indicate an atypical ECG presentation of myocardial infarction.1 Taking this approach may avoid the need for coronary angiography which carries the risks associated with X-ray contrast medium exposure. One of these risks is contrast nephropathy which can lead to acute renal failure, particularly in those with chronic kidney disease or another cause of acute kidney injury. It is likely that, in the case presented by Pearson and Snelson, the contrast medium administration contributed to the acute renal failure and may also have contributed to the haemodynamic compromise through the development of associated acidosis.
With the ready availability of emergency coronary angiography for patients with chest pain and ST elevation on ECG, the authors rightly highlight the importance of considering other diagnoses, which include stress-induced (Tako-Tsubo) cardiomyopathy, pulmonary embolism and dissection of the thoracic aorta.1 Clearly it is important to perform emergency coronary angiography if there is any doubt about the diagnosis of ST elevation myocardial infarction in order to avoid delays in reperfusion in patients with a confirmed diagnosis, but the case presented by the authors demonstrates how an alternative management may be appropriate when emergency echocardiography is available.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2014 Royal College of Physicians
Reference
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- Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC),
- Steg PG,
- James SK,
- Atar D,
- et al.
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