Correspondence

Electrocardiographic Changes in Intracranial Hemorrhage Mimicking Myocardial Infarction

N Engl J Med 2003; 349:1874-1875November 6, 2003

Article

To the Editor:

Bailey and Chaitman (Aug. 7 issue)1 present an electrocardiogram from a patient with a traumatic intracerebral hemorrhage. The electrocardiogram shows rather marked ST-segment and T-wave abnormalities, and the authors state that the abnormalities mimic those of myocardial infarction. I believe the abnormalities are actually due to severe generalized epicardial injury and ischemia; they are not imitators.

The ST-segment and T-wave abnormalities are caused by an abrupt elevation of serum catecholamine levels.2-5 An excess of catecholamines can damage myocytes directly and can also lead to generalized spasm of the coronary arteries. Actual cardiac infarction can result, especially if coronary atherosclerosis is present. This type of myocardial damage may be seen in patients who inject cocaine, those who are receiving intravenous norepinephrine, and those who have pheochromocytoma, startle reaction (“deer hunter's heart attack”), or a severe emotional crisis.2-5

The word “mimicking” in the title of the article is misleading, and the words “erroneous diagnosis” at the end of the article are not correct. The abnormalities on the electrocardiogram are real: they are the result of epicardial injury and ischemia due to abruptly elevated catecholamine levels.

J. Willis Hurst, M.D.
Emory University, Atlanta, GA 30322
jhurst@emory.edu

5 References

1. 1

   Bailey WB, Chaitman BR. Electrocardiographic changes in intracranial hemorrhage mimicking myocardial infarction. N Engl J Med 2003;349:561-561
   Full Text | Web of Science | Medline

2. 2

   Caplan LR, Hurst JW, Chimowitz MI. Clinical neurocardiology. New York: Marcel Dekker, 1999:310-3.
   

3. 3

   Schenk EA, Moss AJ. Cardiovascular affects of sustained norepinephrine infusions. II. Morphology. Circ Res 1966;18:605-615
   Web of Science | Medline

4. 4

   Benedict CR, Loach AB. Sympathetic nervous system activity in patients with subarachnoid hemorrhage. Stroke 1978;9:237-244
   CrossRef | Web of Science | Medline

5. 5

   Connor RCR. Heart damage associated with intracranial lesions. Br Med J 1968;3:29-31
   CrossRef | Web of Science | Medline

Author/Editor Response

We appreciate Dr. Hurst's comments regarding the potential cause of the marked ST-segment and T-wave abnormalities in our 19-year-old patient, but we do not believe that the electrocardiographic pattern of acute injury was the result of severe generalized epicardial injury and ischemia. The electrocardiographic abnormality persisted for more than 24 hours, yet the echocardiogram revealed normal systolic and diastolic left ventricular function. Four serial measurements of cardiac troponin I (a sensitive biomarker of myocardial necrosis) were obtained because of the abnormal electrocardiographic finding, and all were within normal limits — a finding similar to that in a report by others who used the less specific creatine kinase MB test.1,2 Furthermore, normal autopsy findings in patients with intracranial hemorrhage and marked ST-segment and T-wave abnormalities have been reported.3,4

Myocardial ischemia or infarction can certainly occur in patients with an intracranial hemorrhage, as Dr. Hurst points out, but we believe the electrocardiographic abnormalities in our patient are more likely explained by cardiac autonomic dysfunction as a result of the left temporal intracranial hemorrhage.

Brian Bailey, M.D.
Bernard Chaitman, M.D.
Saint Louis University School of Medicine, St. Louis, MO 63110-0250
chaitman@slu.edu

4 References

1. 1

   Katta SR, Berk WA. Hypertensive intracerebral hemorrhage simulating acute myocardial infarction. Ann Emerg Med 1992;21:1002-1005
   CrossRef | Web of Science | Medline

2. 2

   Khechinashvili G, Asplund K. Electrocardiographic changes in patients with acute stroke: a systematic review. Cerebrovasc Dis 2002;14:67-76
   CrossRef | Web of Science | Medline

3. 3

   Brunninkhuis LGH. Electrocardiographic abnormalities suggesting myocardial infarction in a patient with severe cranial trauma. Pacing Clin Electrophysiol 1983;6:1336-1340
   CrossRef | Web of Science | Medline

4. 4

   Cropp GJ, Manning GW. Electrocardiographic changes simulating myocardial ischemia and infarction associated with spontaneous intracranial hemorrhage. Circulation 1960;22:25-38
   Web of Science | Medline