key: cord-0024279-ev1flkgg
authors: Prakash, Sai Durga; Kapil, Anish; Deepti, Siddharthan
title: ST‐segment elevation in a critically ill patient: Greek letters, war helmets, and broken hearts
date: 2021-09-12
journal: J Arrhythm
DOI: 10.1002/joa3.12633
sha: 17ee3a1ab5d013d4b5eeb74c9e2e4bcd376f076c
doc_id: 24279
cord_uid: ev1flkgg

nan

A 57-year-old female was admitted to intensive care unit for severe COVID-19 pneumonia. Her immediate past history was notable for hysterectomy followed by radiotherapy for carcinoma cervix 4 months back, and exploratory laparotomy for subacute intestinal obstruction 1 month before current hospitalization. Evaluation revealed signs of abdominal infection with rigidity and purulent discharge from the suture line. She was hypotensive and acidotic requiring inotropic support and invasive ventilation. A 12-lead electrocardiogram (ECG, Figure 1A ) was performed because STsegment elevation was observed on ICU telemetry on second day of admission. A second ECG was repeated 2 hours later ( Figure 1B) .

What are the findings in the ECGs in Figure 1 ? How should these observations be analyzed?

The QRS-ST complex in Figure 1A is characteristic of the "lambda wave" ST-segment elevation pattern in leads I, II, III, aVF, and V3 to V6. There is a steep upslope coinciding with the ascend- orrhage, sepsis, and metabolic derangements. 4 The mechanism is presumed to be a prolongation of repolarization similar to that seen in long QT syndrome secondary to catecholaminergic excess seen in these conditions. Recently, SHS has been described in association with Takotsubo cardiomyopathy also. 5

This is the first report where both signs have been observed at different stages in the same patient in association with Takotsubo cardiomyopathy. A unifying explanation will be the shared pathophysiology of adrenergic excess lending credence to the hypothesis that both signs are part of a spectrum of abnormalities in repolarization. Awareness of these different possibilities is important and can help prevent unnecessary and potentially harmful interventions.

Careful attention to the electrocardiogram and the clinical context remains critical in decision making.

Siddharthan Deepti https://orcid.org/0000-0001-6517-3066

Siddharthan Deepti @deepti_sidh

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