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LETTER
Year : 2013  |  Volume : 59  |  Issue : 4  |  Page : 334-335

An uncommon cause of chest pain with electrocardiographic changes


Department of Cardiology, Government Medical College, Kozhikode, Kerala, India

Date of Web Publication17-Dec-2013

Correspondence Address:
M P Ranjith
Department of Cardiology, Government Medical College, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.123181

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How to cite this article:
Ranjith M P, Rajesh K F, Muneer K, Sajeev C G, Krishnan M N. An uncommon cause of chest pain with electrocardiographic changes. J Postgrad Med 2013;59:334-5

How to cite this URL:
Ranjith M P, Rajesh K F, Muneer K, Sajeev C G, Krishnan M N. An uncommon cause of chest pain with electrocardiographic changes. J Postgrad Med [serial online] 2013 [cited 2019 Nov 14];59:334-5. Available from: http://www.jpgmonline.com/text.asp?2013/59/4/334/123181


Sir,

There are reports of electrocardiographic (ECG) changes associated with pneumothorax. [1],[2] However, significant ECG changes associated with bullous lung disease are rarely reported. We report a case of bullous lung disease with ECG changes mimicking coronary artery disease in this paper.

A 52-year-old male, smoker presented to our emergency department with left sided chest pain of acute onset. He was hemodynamically stable. Clinical examination revealed only decreased breath sounds in left lower chest. ECG showed deep narrow T wave inversions in inferolateral leads suggesting a possibility of coronary artery disease [Figure 1]. Serial serum cardiac markers were negative. Chest radiograph showed emphysematous changes and a large bulla involving the left lower lobe [Figure 2]. Computed tomography scan showed emphysematous changes and bullous disease involving lower lobes of both lungs with more involvement on the left side [Figure 3]. Transthoracic echocardiogram was normal. A coronary angiogram showed normal coronaries. Patient was managed with analgesics and became symptom free. Follow-up at Day 30, showed identical ECG changes suggesting that these changes were likely due to the bulla involving left lower lobe.
Figure 1: Electrocardiogram showing deep T wave inversions in inferolateral leads suggestive of coronary artery disease

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Figure 2: Chest radiograph showing emphysematous changes and a large bulla involving left lower lobe

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Figure 3: Computed tomography scan thorax revealing emphysematous changes and bullous disease involving lower lobes of both lungs with more involvement in left

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More than 30% of left sided pneumothoraces are associated with ECG changes. The most common findings are right-axis deviation, low QRS complex voltage, T wave inversion, and loss of R waves in the precordial leads. [3] However, significant ECG changes associated with bullous lung disease are seldom reported. Literature explains T wave changes in pneumothorax by abnormal myocardial repolarization, possibly secondary to: Abnormal myocardial perfusion, intra-pleural and or intra-pericardial pressure fluctuations and increased resistance in the pulmonary circulation. [4] The same may be applied in bullous lung disease. In this case, the ECG changes are likely to be due to the bulla given the normal CAG findings. However, the etiology could only have been confirmed when the changes have resolved after bullectomy which was not done. ECG is often the first test ordered for patients experiencing chest pain. A detailed history and clinical examination are essential to avoid making wrong diagnosis solely on the basis of ECG changes. Clinicians should recognize that the ST, T changes on ECG could be due to non cardiac causes as well.

 
 :: References Top

1.Strizik B, Forman R. New ECG changes associated with a tension pneumothorax: A case report. Chest 1999;115:1742-4.  Back to cited text no. 1
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2.Shiyovich A, Vladimir Z, Nesher L. Left spontaneous pneumothorax presenting with ST-segment elevations: A case report and review of the literature. Heart Lung 2011;40:88-91.  Back to cited text no. 2
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3.Masters AM. The electrocardiographic changes in pneumothorax in which the heart has been rotated: The similarities of some of these changes to those indicating myocardial damage. Am Heart J 1928;3:472-83.  Back to cited text no. 3
    
4.Walston A, Brewer DL, Kitchens CS, Krook JE. The electrocardiographic manifestations of spontaneous left pneumothorax. Ann Intern Med 1974;80:375-9.  Back to cited text no. 4
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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2004 - Journal of Postgraduate Medicine
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