The differential diagnosis of acute pulmonary embolism and ST segment
inferior myocardial infarction
Oscar M.P. Jolobe
PII:
DOI:
Reference:

S0735-6757(15)00078-9
doi: 10.1016/j.ajem.2015.02.016
YAJEM 54803

To appear in:

American Journal of Emergency Medicine

Received date:
Accepted date:

2 February 2015
10 February 2015

Please cite this article as: Jolobe Oscar M.P., The dierential diagnosis of acute pulmonary embolism and ST segment inferior myocardial infarction, American Journal of
Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.02.016

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Title page for the differential diagnosis of acute pulmonary embolism and ST
segment elevation inferior myocardial infarction

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The differential diagnosis of acute pulmonary embolism and ST segment

inferior myocardial infarction

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Oscar M P Jolobe MRCP(UK)., D. PHIL

Manchester Medical Society

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Simon Building

Brunswick Street
Manchester M13 9PL

Oscar M P Jolobe

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Corresponding author

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United Kingdom

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1 Philip Godlee Lodge

842 Wilmslow Road

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Manchester M20 2DS

Relephone:-

44 161 448 9034

e-mail
oscarjolobe@yahoo.co.uk
key words:-pulmonary; embolism; inferior; myocardial; infarct; diagnosis
Running head
Association of pulmonary embolism and myocardial infarction

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The differential diagnosis of acute pulmonary embolism and ST segment
elevation inferior myocardial infarction

Distinct from the scenario of acute pulmonary embolism(APE) masquerading

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as inferior myocardial infarction(AMI)[1], and vice-versa, the clinical scenario

that also needs to be recognised is the one where the two entities are causally

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related[2],[3],[4],[5],[6]. For example, APE may occasionally, give rise to

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AMI(with ST segment elevation in leads II, III, and AVF) when APE-related
dilatation of the pulmonary artery causes compression of the proximal portion
of the right coronary artery. This was the case in a 55 year old woman in
whom the right coronary artery had an anomalous origin from the left

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coronary sinus[2]. Even in the absence of this rare anomaly, when APE is
massive, that, in itself, may cause AMI(including inferior AMI) by generating a

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sudden increase in right ventricular overload, with consequent increase in

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myocardial oxygen demand. Right ventricular infarction occurs when this

demand cannot be met. In one of the 6 cases with autopsy documentation of

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this phenomenon, an ECG recorded approximately one hour before death was
reported as showing inferior necrosis(Case 1)[3]. Paradoxical embolism is
yet another mechanism whereby APE can cause AMI, and this was the case in
two separate case reports where angiographically validated coronary
embolism was associated with ST segment elevation in leads II, III, and AVF. In
both instances the diagnosis of paradoxical embolism was validated by
documentation of patent foramen ovale[4],[5]. Conversely, AMI may be
complicated by APE, as was the case in a 66 year old man in whom serial ECGs
and enzyme studies.confirmed the diagnosis of inferior MI[6]. In that

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patient APE was attributable to embolization from a right ventricular
thrombus[6]. Finally, in the differential diagnosis of inferior AMI vs APE,

cognisance must also be taken of aortic dissection, given the fact that elevation

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in D-dimer levels is a marker, both for APE and aortic dissection[7]. Aortic
dissection may, in turn, sometimes be associated with ST segment elevation in

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leads II, III, and AVF[8],[9],[10]. In one such case angiographically proven APE

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was an associated feature[9]. In another case, the presenting feature was

pleuritic chest pain in association with a D-dimer level of 3,520 (reference
range 0-275)[10], the latter association being a potential source of confusion
with APE. Even in the absence of pleuritic chest pain, aortic dissection may

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simulate APE by causing hypoperfusion of the right lung when the dissecting

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haematoma compresses the right pulmonary artery[11],[12]. The resulting

image, on pulmonary perfusion scintigraphy, is consistent with massive

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pulmonary embolism[12].In conclusion, increasing recognition has to be made

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of the association of APE and AMI, especially when the two disorders are
causally related.

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Diagnosing acute pulmonary embolism masquerading as inferior myocardial

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