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Segmental ST-T changes in Hypokalemia Suggesting Subendocardial Injury: a Case Report

Author : Ayu A.P., Hidayat I.R., Dewi T.T., Rakhmawati I., Pertiwi D.Y., Rostiati D.
Upload Date : 19-04-2018

Background: Myocyte depolarization and repolarization depend on intra- and extracellular shifts in ion gradients, abnormal serum electrolyte levels can have profound effects on cardiac conduction and the electrocardiogram (ECG).1 The most remarkable electrocardiography alterations in electrolyte imbalance are due to changes in serum potassium levels.2 Here we report a hypokalemia patient with segmental ST-T changes with elevating cardiac enzymes suggesting subendocardial injury.

Case: A 32-year-old, woman, presented to our Emergency Room with a chest discomfort. On the day of presentation the patient also felt generalized weakness. The 12-lead ECG showed sinus rhythm at 140 per minute and a marked ST-segment depression in leads V3-V6, I, II, III, and aVF. Troponin-T levels were 157 ng/ml. The initial diagnosis of the emergency physician was non ST elevation myocardial infarction, and the patient was admitted to our Cardiology Department for further evaluation. Trans-thoracic echocardiography was normal, with no evidence of regional wall motion abnormalities. A more detailed history revealed upper abdominal pain, nausea, vomitting and diarrhea for  one week. Physical examination found a dehydrated patient with regular heart rate of 130 beats per minute and blood pressure of 90/60 mmHg. The pulmonary and cardiac examinations were normal. The abdomen was soft and non-tender, orienting diagnosis toward a case of acute gastroenteritis. Serum chemistries were notable for a potassium concentration of 2.66 mmol per liter and sodium concentration of 151 mmol per liter. After potassium supplementation through intravenous infusion, the patient’s serum electrolyte levels and ST segments on electrocardiogram were normalized.

Discussion: Hypokalemia induced ST segment depression may simulate subendocardial injury or ischemia and ECG correlates of hypokalemia can be confused with myocardial ischemia.4 In this case, there was marked ST depression, resembling the subendocardial injury. But, the result of echocardiography showed none of the regional wall motion abnormalities. Profound anamnesis and electrolye serum examination, revelead that this patient had hypokalemia. The response to potassium correction confirmed that the ECG abnormalities were secondary to severe hypokalemia.

Conclussion: Since severe hypokalemia may mimicking myocardial ischemia, physician should consider hypokalemia when encounter cases with ST changes, especially for the patient who has risk factor for it.

KEYWORDS : Hypokalemia, Myocardial Ischemia, ST Segment Depression

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