Severe hypercalcaemia mimicking acute myocardial infarction
Editor – We read with interest the lesson of the month by Wesson and colleagues (Clin Med April 2009 pp 186–7) which describes a patient admitted with vague chest pain. The patient was found to have severe hypercalcaemia (5.09 mmol/l) and an abnormal electrocardiogram (ECG). A past medical history of ischaemic heart disease (IHD), coronary angioplasty, hypertension and left ventricular failure was documented. The authors explain that the ECG in Fig 1 showed ST segment elevation in leads V1 to V5 with Q waves and poor R wave progression in the inferior leads. They conclude that these changes were due to hypercalcaemia, noting that this has only been described in two previous cases.
Having studied the ECG shown in Fig 1, we find that it also shows voltage criteria for left ventricular hypertrophy (LVH) and poor R wave progression from leads V1 to V4. We do not agree that there was poor R wave progression in the inferior leads. We would therefore suggest there are other more common diagnoses that might explain the abnormalities shown on this ECG.
Firstly, it is possible that the patient had previously developed a left ventricular aneurysm secondary to IHD, resulting in persistent anterior ST elevation. The poor R wave progression seen in leads V1 to V4 would suggest that there has been significant infarction in the anterior territory that would potentially predispose to this diagnosis. Another explanation is that some patients with voltage criteria for LVH on their ECG develop repolarisation changes that can include anterior ST segment elevation.1 Cardiomyopathies, such as hypertrophic cardiomyopathy (which can present in older patients), can also cause voltage criteria for LVH and ST elevation.2 A last possibility which would tie in with the chest pain, would be a diagnosis of pericarditis. The ST elevation in V5 is saddle shaped which would be in keeping with this, although the other elevated ST segments do not have this morphology. There is also no PR depression seen.
The authors do not comment on previous ECGs or any current or previous echocardiographic findings. Without considering these, and the more common causes of ST elevation, we do not feel that the authors are justified in making this very rare association.
Footnotes
Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2009 Royal College of Physicians
References
Article Tools
Citation Manager Formats
Jump to section
Related Articles
- No related articles found.