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ST segment elevation on ECG has other causes apart from myocardial infarction (MI) and in the thrombolytic treatment era, this may expose the patient to unnecessary drug treatment or invasive procedures that have the potential risk of complications.
A 30 year old insulin dependent diabetic man was treated for severe diabetic keto-acidosis. He was a smoker with a 15 year history of diabetes mellitus. His potassium on admission was 6.5 mmol/l and his ECG showed tall, peaked T wave (panel A). Eight hours following admission, ST segment elevation was noted on the monitor and an inferolateral acute MI pattern (panel B) was confirmed by ECG. The patient had no chest pain but was thrombolysed with tenecteplase with no resolution of his ST segment elevation; his potassium at the time of the ST elevation was 6.9 mmol/l. He was referred to our centre for coronary angiography, which surprisingly was entirely normal but with poor left ventricular function. Cardiac troponin T was raised at 2.54 μg/l and the ST segment elevation was improving gradually. He was treated medically and made a good recovery and was discharged home seven days later.
Hyperkalaemia may produce multiple ECG abnormalities, including ST segment elevation and pseudoinfarct pattern with resolution of these abnormalities on correcting the hyperkalaemia. When faced with a patient with hyperkalaemia, ST segment elevation may pose a diagnostic and management dilemma regarding the use of thrombolysis. We suggest that while measures are undertaken to correct the metabolic derangement, an immediate referral for coronary angiography should be the first approach. Alternatively, bedside echocardiography, to demonstrate any regional wall motion abnormalities, and cardiac troponin measurement can be used where angiography is not available.
In case of doubts, thrombolysis should not be withheld, as it remains largely safe with life saving effects.