Clinical Review & Education

Challenges in Clinical Electrocardiography

ST-Segment Elevation Myocardial Infarction Mimic

Unearthing the Hidden Truth
Chuan-Hai Zhang, MD; Ting-Ting Li, MD

A woman in her 60s with a history of hypertension presented to
the emergency department with sudden-onset chest pain. She had
no history of any acute febrile illness or family history of sudden car-
diac death. She was tachycardic with a pulse of 120 beats/min. Her
blood pressure was normal. Her white blood cell count was
14 300/μL (normal range: 3500-9500/μL; to convert to ×109/L, mul-
tiply by 0.001), while the serum calcium concentration was within
the normal limits. High-sensitivity troponin I level was 1.15 ng/mL (nor-
mal range: <0.015 ng/mL; to convert to μg/L, multiply by 1.0), and
the brain-type natriuretic peptide level was 1060.30 pg/mL (nor-
mal range: 0-100 pg/mL; to convert to ng/L, multiply by 1.0). Her
admission electrocardiogram (ECG) is shown in the Figure, A.
Questions: What is your interpretation of this ECG? Based on
the patient’s clinical presentation, what is the cause of the ECG
findings?
Interpretation
The admission ECG revealed sinus tachycardia, with a PR-segment el-
evation in lead aVR and a PR-segment depression in leads I, II, III, aVF,
and V4 to V6. Furthermore, an ST-segment elevation was noted in leads
II, III, aVF, and V2 to V6, whereas an ST-segment depression was noted
in lead aVR.
We observed different characteristics in a series of ECGs obtained
at different times (Figure, B). All of the ECGs could be separated into 4

Figure. Electrocardiograms at Admission and Different Time Points

A Electrocardiogram at admission

B Electrocardiograms obtained at different times

Day 2 Day 4 Day 9 Day 12 Day 17 Day 49 Day 2 Day 4 Day 9 Day 12 Day 17 Day 49

I V1

II V2

III V3

aVR V4

A, Massive PR-segment depressions

aVL V5
and ST-segment elevations in the
initial electrocardiogram. B, Dynamic
and diffuse T-wave inversions in the
aVF V6
electrocardiograms obtained at
different times.

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 Clinical Review & Education Challenges in Clinical Electrocardiography

stages: (1) ST-segment elevation after symptom onset (Figure, A); (2)
initial T-wave inversion after resolution of ST-segment elevation on day
2; (3) transient improvement in T-wave inversions on day 4; and (4)
deeper T-wave inversions that persisted until the last follow-up.
Furthermore, the initial QTc interval was short; however, it gradu-
ally prolonged in the subsequent ECGs and reached the maximum
on day 12 of hospitalization. This dynamic change in the QTc inter-
vals, along with the absence of a family history of sudden cardiac
death, dispelled the suspicion of short QT syndrome.
Clinical Course
Coronaryangiographyrevealednormalcoronaryarteries,whileleftven-
triculography confirmed systolic apical ballooning. On day 2 of hospi-
talization,thehigh-sensitivitytroponinIlevelwas0.11ng/mL.Thesefind-
ings were highly suggestive of Takotsubo cardiomyopathy (TTC).
Although, was it really TTC? Contrast-enhanced abdominal com-
puted tomography revealed an enhanced left-adrenal heterogeneous
mass measuring 4.1 × 3.4 cm. The patient was referred to a surgeon for
resection,andthemasswaspathologicallyconfirmedtobeapheochro-
mocytoma. The final diagnosis was pheochromocytoma-induced
cardiomyopathy. One month after surgery, the patient’s hypertension
resolved.
Discussion
Pheochromocytoma is a rare endocrine tumor that originates in the
adrenal medulla and secretes catecholamine. Typical symptoms in-
clude the triad of headache, sweating, and palpitations. The clinical
expression of pheochromocytoma includes many cardiovascular
manifestations, such as labile hypertension, tachycardia, cardio-
genic shock, and pheochromocytoma-induced cardiomyopathy.
Thus, pheochromocytoma is often referred to as the “great mimic.”
Pheochromocytoma-induced cardiomyopathy has been found to
be similar to TTC. The pathogenesis of TTC, similar to that of pheochro-
mocytoma, involves catecholamine excess. Clinical presentation in-
volves chest pain, elevated cardiac enzyme levels, wall motion abnor-
malities, and electrocardiographic changes, all of which share striking
similarities to acute coronary syndrome.1 The ECG abnormalities in TTC
may include PR-segment depression, ST-segment elevation, T-wave in-
version, QT interval prolongation, and abnormal Q waves. The ECG fea-
tures of TTC are dynamic and characterized by different evolutionary
patternsovertime(Figure).AcomprehensiveunderstandingoftheECG
characteristicsofTTCatdifferentstageswouldallowphysicianstomake
an accurate, timely diagnosis.
Typically, PR-segment depression is reported as a landmark of the
early phase of acute pericarditis, but it has also been described in TTC.
Zorzi et al2 reported that PR-segment depression is present in nearly
two-thirds of patients with TTC. This is because the steep increase in
catecholamine levels during TTC could negatively affect atrial repolar-
ization and influence the PR-segment. Because our patient had no his-
tory of any acute febrile illness, the PR-segment depression was con-
sidered to have been caused by excessive catecholamine secretion
rather than by acute pericarditis.
In TTC, ST-segment elevation is more extensive (involving the
anterior and inferior regions), while ST-segment depression most fre-
quently occurs in lead aVR. Conversely, in anterior myocardial in-
farction, the prevalence of ST-segment depression in lead aVR is low.
Takotsubo cardiomyopathy usually leads to diffuse T-wave
inversions.3 Moreover, T-wave inversions are often greater in mag-
nitude in TTC than in acute coronary syndrome and can resolve spon-
taneously within a few weeks to several months.
In one study, 200 cases of TTC from countries participating in
the International Takotsubo Registry were categorized into 2 types:
ST-segment elevation TTC and non–ST-segment elevation TTC; these
were then compared with cases of ST-segment elevation myocar-
dial infarction (STEMI) and non–ST-segment elevation myocardial in-
farction (NSTEMI), respectively.4 It was found that in case of ST-
segment elevation, ST-segment elevation in the anteroseptal leads
and ST-segment depression in aVR were 100% specific for TTC vs
STEMI. In case of non–ST-segment elevation, ST-segment depres-
sion in aVR, along with a concomitant T-wave inversion in any lead,
was found to be 100% specific for TTC vs NSTEMI. Based on these
findings, the ECG changes in the ST-segment elevation and T-wave
inversion stages in the present patient may be suggestive of TTC.
The key to diagnosing pheochromocytoma-induced cardiomyo-
pathy is awareness of the condition and its presentation. Pheochromo-
cytoma should be considered as a differential diagnosis when diagnos-
ing TTC. When ECG changes are consistent with the ECG characteris-
tics of TTC, the presence of leukocytosis without evidence of infection
is suggestive of pheochromocytoma-induced TTC because the surge
ofcatecholaminereleasecancauseanelevatedwhitebloodcellcount.5
Take-home Points
• The ECG abnormalities in TTC may include PR-segment depres-
sion, ST-segment elevation, T-wave inversion, QT interval prolon-
gation, and abnormal Q waves.
• Nearly two-thirds of all patients with TTC demonstrate PR-
segment depression.
• In distinguishing TTC from STEMI and NSTEMI, ST-segment eleva-
tion in the anteroseptal leads and ST-segment depression in aVR
are 100% specific for TTC vs STEMI; ST-segment depression in aVR,
along with a concomitant T-wave inversion in any lead, is 100% spe-
cific for TTC vs NSTEMI.

ARTICLE INFORMATION REFERENCES JAMA Intern Med. 2015;175(5):842-844. doi:10.1001/

Author Affiliations: Department of Cardiology, The
First Affiliated Hospital of Jinzhou Medical
University, Jinzhou, Liaoning Province, China.
Corresponding Author: Chuan-Hai Zhang, MD,
Department of Cardiology, The First Affiliated
Hospital of Jinzhou Medical University, Renmin St,
Jinzhou, Liaoning Province, China 121000
(zch8598145@yeah.net).
Published Online: September 13, 2021.
doi:10.1001/jamainternmed.2021.4427
Conflict of Interest Disclosures: None reported.
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