Images in Clinical Medicine

“Pseudoinfarction” Pattern Due to Hyperkalemia

Kyuhyun Wang, M.D.

N Engl J Med 2004; 351:593August 5, 2004

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A 38-year-old man presented to the emergency department with nausea, vomiting, and epigastric pain. The patient had type 1 diabetes mellitus and was being treated with insulin. He was also taking lisinopril for the treatment of hypertension.

The initial electrocardiogram (Panel A) revealed sinus tachycardia and ST-segment elevation in leads V₁ to V₃ — findings highly suggestive of acute anteroseptal myocardial infarction. Peaked T waves were noted in leads II, III, aVF, and V₃ to V₆.

The serum glucose concentration was 839 mg per deciliter (46.6 mmol per liter), the arterial blood pH was 7.21, and the serum potassium concentration was 7.9 mmol per liter. The diagnosis of diabetic ketoacidosis was made. When the electrocardiogram was repeated several hours later, after the potassium concentration was lowered to 5.1 mmol per liter with treatment (Panel B [lead V₅ is not placed]), the ST-segment elevation disappeared completely, as did the peaked T waves. This case is an example of hyperkalemia causing a “pseudoinfarction” pattern. The clue to the correct diagnosis is the T wave in V₄, which is tall, narrow, and pointed, with a short QT interval. The tall T waves that are characteristic of hyperacute ischemic changes tend to be associated with a long QT interval, and the T waves are broad rather than narrow and pointed.

Kyuhyun Wang, M.D.
Hennepin County Medical Center, Minneapolis, MN 55415

Citing Articles (8)

Citing Articles

1. 1

   Armin Wessel, Karsten Harms, Kambiz Norozi. (2011) Long-term follow-up of pseudoinfarction pattern in two children. Clinical Research in Cardiology 100:6, 539-541
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2. 2

   Subhash Chandra, Vikas Singh, Mahendra Nehra, Dipti Agarwal, Nishit Singh. (2011) ST-segment elevation in non-atherosclerotic coronaries: a brief overview. Internal and Emergency Medicine 6:2, 129-139
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3. 3

   Marc A. Bellazzini, Tom Meyer. (2010) Pseudo-Myocardial Infarction in Diabetic Ketoacidosis with Hyperkalemia. The Journal of Emergency Medicine 39:4, e139-e141
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4. 4

   Enbiya Aksakal, Taner Ulus, Ednan Bayram, Hakan Duman. (2009) Acute inferior pseudoinfarction pattern in a patient with normokalemia and diabetic ketoacidosis. The American Journal of Emergency Medicine 27:2, 251.e3-251.e5
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5. 5

   Carol Jacobson. (2008) Myocardial Infarction Mimics ST Segments. AACN Advanced Critical Care 19:2, 245-248
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6. 6

   Henry S. Loeb, William P. Gunnar, Donald D. Thomas. (2007) Is new ST-segment elevation after coronary artery bypass of clinical importance in the absence of perioperative myocardial infarction?. Journal of Electrocardiology 40:3, 276-281
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7. 7

   Laszlo Littmann, Michael H. Monroe, Lee Taylor, William D. Brearley. (2007) The hyperkalemic Brugada sign. Journal of Electrocardiology 40:1, 53-59
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8. 8

   Niels Moller, Anne-Catherine H. Foss, Claus H. Gravholt, Ulrik M. Mortensen, Steen Hvitfeldt Poulsen, Carl E. Mogensen. (2005) Myocardial injury with biomarker elevation in diabetic ketoacidosis. Journal of Diabetes and its Complications 19:6, 361-363
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