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Chest Pain and ECG Changes in a 61-Year-Old WomanChest Pain and ECG Changes in a 61-Year-Old Woman FREE TO VIEW

Ori Vatury, MD; Naser M. Ammash, MD; Marie Christine Aubry, MD; Philip A. Araoz, MD; Lawrence J. Sinak, MD; Benjamin F. Wong, MD; Kyle W. Klarich, MD
Author and Funding Information

From the Mayo Clinic, Rochester, MN.

Correspondence to: Ori Vatury, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: vatury.ori@mayo.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1676-1679. doi:10.1378/chest.12-0410
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A 61-year-old white woman presented to her local ED with 12 h of severe substernal chest pain, which increased with deep inspirations and movement and did not respond to nitroglycerin. A similar presentation was noted by the patient 2 days earlier, but it was resolved with aspirin.

Her medical history was significant for type 2 diabetes treated with insulin, hypertension, heavy smoking, COPD, and mild anemia noted a year earlier, the cause of which was not determined. The patient had been evaluated in the past for coronary artery disease because of episodes of nonspecific chest pain and major cardiovascular risk factors and had undergone two coronary angiograms; the last one, in 2008, showed nonsignificant coronary artery disease.

Physical Examination

On physical examination, the patient appeared to be in mild distress, especially when coughing. Vital signs were normal, but shallow breathing was noted. The cardiovascular and lung examination results were unremarkable.

Laboratory Findings

Shortly after arrival at the ED, laboratory values were measured, and an ECG was performed (Fig 1). Based on the ECG and the clinical presentation, the patient was transferred to another facility with percutaneous coronary intervention capabilities to undergo an emergency coronary angiogram.

Figure Jump LinkFigure 1 ECG on arrival showing ST segment elevation in inferior leads with reciprocal changes in I and aVL.Grahic Jump Location

The coronary angiogram showed nonsignificant coronary artery disease and inferior wall akinesis. Laboratory results at that time were significant for a very mild elevation in troponin (less than twice the upper normal limit), CBC count was remarkable only for normocytic normochromic anemia with a hemoglobin level of 9.8 mg/dL, and no leukocytosis or eosinophilia was noted. Following the angiogram, the patient was sent for further evaluation with a transthoracic echocardiogram (Fig 2). This transthoracic echocardiogram showed a large homogeneous mass obliterating the right ventricular apex and infiltrating nearly the entire right ventricular myocardium; the ventricular septum appeared infiltrated by the mass, with associated akinesis of the septum and severe right ventricular systolic dysfunction. To further evaluate the mass, a chest and abdominal CT scan (with contrast) was performed (Fig 3). A biopsy of the psoas mass was conducted for suspected cancer with cardiac metastases.

Figure Jump LinkFigure 2 A, Echocardiogram image from subcostal window showing a large mass in the right ventricle. B, Echocardiogram image from apical window with agitated saline showing a large right ventricular mass occupying the apex and the septum.Grahic Jump Location
Figure Jump LinkFigure 3 A, Chest CT scan slice with contrast showing an infiltrating mass that has replaced the inferior wall of both the left and the right ventricle. B, Abdominal CT scan slice showing a mass in the left psoas muscle.Grahic Jump Location
What is the diagnosis?
Diagnosis: Metastatic adenocarcinoma infiltrating the right ventricle and the inferior and septal left ventricle walls

Metastatic spread to the heart is fairly common, with an prevalence of 1.23% in autopsy studies; however, in many cases, the metastases are clinically silent. The most common tumors that send metastasis involving the heart are carcinomas originating from the lung, the breast, and the esophagus; lymphoma; and melanoma. The metastatic tumor can spread via direct extension (as is the case for mediastinal tumors such as esophageal cancer), via the lymphatic system (a common pathway for breast and lungs cancers), or via the blood stream (a common mechanism for melanoma and leukemia), and, rarely, as a direct extension through the venous system to the right atrium (seen in renal cell carcinoma, for example).

The site of cardiac involvement and the clinical manifestation depend on the route of the metastases. Lymphatic spread often involves the pericardium and can cause hemodynamically significant pericardial effusion or pericarditis. Hematogenous spread involves the myocardium itself, mainly the left ventricular free wall and interventricular septum (because they are the most heavily vascularized structures). Involvement of the myocardium can present as signs and symptoms of heart failure because of obstruction of normal blood flow (inflow or outflow tract obstruction) or as arrhythmias because of infiltration of the myocardium. Of note, metastases may also embolize distally. The diagnosis of cardiac metastases is based on a constellation of symptoms, clinical findings, and ECG findings, and, very importantly, by using noninvasive imaging modalities such as echocardiography and CT imaging.

New symptoms of heart failure (such as shortness of breath) and physical findings consistent with heart failure, such as elevated jugular venous pulse and leg edema, in a patient with known malignancy can be the first clue of cardiac metastases. Patients may present with chest pain related to pericarditis (when the precardium is involved) secondary to external compression of the coronary arteries or related atelectasis or pulmonary embolism due to metastases elsewhere. The cardiac examination is often unremarkable (although murmurs related to blood flow obstruction and pericardial friction rub due to pericarditis can be heard).

The ECG manifestation of infiltration of the myocardium by metastasis may differ. Atrial and ventricular arrhythmias are fairly common when the atria or ventricles are infiltrated by the metastases.

ST-segment changes are noted in 40% to 78% of patients with identified cardiac metastases (by autopsy or by echocardiogram). Furthermore, ST-segment elevation has been reported as having a specificity of 84% in patients with proven echocardiographic evidence of cardiac infiltration.

ST-segment elevation as a presenting finding for patients without known metastatic disease has been described rarely in the literature, only in a few case reports. In these case reports, the cause of the ST-segment elevation was often misdiagnosed initially and suspected on the basis of an echocardiogram after a myocardial infarction had been ruled out. Often in these cases, the specific cardiac biomarkers (such as troponin) are not elevated markedly because the ST changes seen are presumably related to infiltration of the myocardium and not to ischemic damage and necrosis of the myocardium.

There are no large case control series or guidelines recommending the appropriate treatment for cardiac metastasis. Surgical resection is rarely an option and treatment is either palliative or aimed against the primary tumor.

The role of radiation (for radiation-sensitive tumors such as lymphomas) is not well defined. There are several case reports describing successful palliative treatment with regression of metastases; however, radiation can cause cardiac damage (fibrosis, coronary disease, valvular disease, and pericardial disease) even in a low dosage, and the amount of radiation acceptable and whether the benefits outweigh the harm have not been determined.

Our case had a somewhat unusual presentation of a metastatic tumor, with the first presentation being ST-segment elevation and chest pain initially assumed to be inferior wall ST-elevation myocardial infarction. The diagnosis was based on the normal angiogram and a comprehensive echocardiogram, which raised the suspicion that there was a cardiac mass, with the final diagnosis made with the use of chest and abdominal CT scans that showed a metastatic tumor spread, confirmed with a needle biopsy of the psoas. Interestingly, the primary tumor was not identified.

Clinical Course

After initial work-up, the patient was admitted to the cardiac service for further evaluation and pain control. She was discharged to her home after a few days, to receive palliative chemotherapy. She continued to receive palliative chemotherapy, which was not effective, and she died approximately 2 months after the diagnosis.

  • 1. Metastases infiltrating the myocardium are a rare but possible cause of ST-segment elevation not related to myocardial ischemia and should be considered in the differential diagnosis of ST-segment elevation.

  • 2. In patients with a known history of metastatic cancer, ST changes (possibly ST-segment elevation) may be the initial presentation of metastasis to cardiac structures.

  • 3. Echocardiographic evaluation of patients presenting with chest pain and ECG changes is of great importance.

  • 4. There is no definite well-defined treatment of metastasis involving the heart.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Cates CU, Virmani R, Vaughn WK, Robertson RM Electrocardiographic markers of cardiac metastasis. Am Heart J. 1986;112(6):1297-1303. [CrossRef] [PubMed]
 
Lestuzzi C, Nicolosi GL, Biasi S, Piotti P, Zanuttini D Sensitivity and specificity of electrocardiographic ST-T changes as markers of neoplastic myocardial infiltration. Echocardiographic correlation. Chest. 1989;95(5):980-985. [CrossRef] [PubMed]
 
Lam KY, Dickens P, Chan AC Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993;117(10):1027-1031. [PubMed]
 
Rodrigues AC, Abreu E, Demarchi LM, Mathias W Jr, Leal SM, Andrade JL Lung neoplasm mimicking an acute lateral myocardial infarction. J Am Soc Echocardiogr. 2003;16(11):1198-1200. [CrossRef] [PubMed]
 
Wang K, Asinger RW, Marriott HJ ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med. 2003;349(22):2128-2135. [CrossRef] [PubMed]
 
Reynen K, Köckeritz U, Strasser RH Metastases to the heart. Ann Oncol. 2004;15(3):375-381. [CrossRef] [PubMed]
 
Pan KL, Wu LS, Chung CM, Chang ST, Lin PC, Hsu JT Misdiagnosis: cardiac metastasis presented as a pseudo-infarction on electrocardiography. Int Heart J. 2007;48(3):399-405. [CrossRef] [PubMed]
 
Samaras P, Stenner-Liewen F, Bauer S, et al Images in cardiovascular medicine. Infarction-like electrocardiographic changes due to a myocardial metastasis from a primary lung cancer. Circulation. 2007;115(10):e320-e321. [PubMed]
 
Ekmektzoglou KA, Samelis GF, Xanthos T Heart and tumors: location, metastasis, clinical manifestations, diagnostic approaches and therapeutic considerations. J Cardiovasc Med. 2008;9(8):769-777. [CrossRef]
 
Dasgupta T, Barani IJ, Roach M III Successful radiation treatment of anaplastic thyroid carcinoma metastatic to the right cardiac atrium and ventricle in a pacemaker-dependent patient. Radiat Oncol. 2011;6(:16-. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 ECG on arrival showing ST segment elevation in inferior leads with reciprocal changes in I and aVL.Grahic Jump Location
Figure Jump LinkFigure 2 A, Echocardiogram image from subcostal window showing a large mass in the right ventricle. B, Echocardiogram image from apical window with agitated saline showing a large right ventricular mass occupying the apex and the septum.Grahic Jump Location
Figure Jump LinkFigure 3 A, Chest CT scan slice with contrast showing an infiltrating mass that has replaced the inferior wall of both the left and the right ventricle. B, Abdominal CT scan slice showing a mass in the left psoas muscle.Grahic Jump Location

Tables

Suggested Readings

Cates CU, Virmani R, Vaughn WK, Robertson RM Electrocardiographic markers of cardiac metastasis. Am Heart J. 1986;112(6):1297-1303. [CrossRef] [PubMed]
 
Lestuzzi C, Nicolosi GL, Biasi S, Piotti P, Zanuttini D Sensitivity and specificity of electrocardiographic ST-T changes as markers of neoplastic myocardial infiltration. Echocardiographic correlation. Chest. 1989;95(5):980-985. [CrossRef] [PubMed]
 
Lam KY, Dickens P, Chan AC Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993;117(10):1027-1031. [PubMed]
 
Rodrigues AC, Abreu E, Demarchi LM, Mathias W Jr, Leal SM, Andrade JL Lung neoplasm mimicking an acute lateral myocardial infarction. J Am Soc Echocardiogr. 2003;16(11):1198-1200. [CrossRef] [PubMed]
 
Wang K, Asinger RW, Marriott HJ ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med. 2003;349(22):2128-2135. [CrossRef] [PubMed]
 
Reynen K, Köckeritz U, Strasser RH Metastases to the heart. Ann Oncol. 2004;15(3):375-381. [CrossRef] [PubMed]
 
Pan KL, Wu LS, Chung CM, Chang ST, Lin PC, Hsu JT Misdiagnosis: cardiac metastasis presented as a pseudo-infarction on electrocardiography. Int Heart J. 2007;48(3):399-405. [CrossRef] [PubMed]
 
Samaras P, Stenner-Liewen F, Bauer S, et al Images in cardiovascular medicine. Infarction-like electrocardiographic changes due to a myocardial metastasis from a primary lung cancer. Circulation. 2007;115(10):e320-e321. [PubMed]
 
Ekmektzoglou KA, Samelis GF, Xanthos T Heart and tumors: location, metastasis, clinical manifestations, diagnostic approaches and therapeutic considerations. J Cardiovasc Med. 2008;9(8):769-777. [CrossRef]
 
Dasgupta T, Barani IJ, Roach M III Successful radiation treatment of anaplastic thyroid carcinoma metastatic to the right cardiac atrium and ventricle in a pacemaker-dependent patient. Radiat Oncol. 2011;6(:16-. [CrossRef] [PubMed]
 
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