B50-06 When Pancreatitis Tricks the Heart: A Case of Acute Pancreatitis Masquerading as an Acute Inferior Myocardial Infarction

Abstract Introduction Patients presenting with chest pain initiate a clinician’s work-up for life-threatening conditions including acute coronary syndrome, in which electrocardiogram (ECG) and troponins are often the first orders. When ST-elevations are noted, this prompts clinicians to consult cardiology for possible acute myocardial infarction; however, not all ST-elevations are typical. We present a case in which a patient with a typical presentation had atypical results. Case Presentation A 57-year-old male with history of alcohol use, hypertension, and hyperlipidemia presented with sharp, severe pain in the epigastric abdomen and chest, radiating to the upper back. He also had associated nausea, vomiting, and lightheadedness without loss of consciousness. Vitals were significant for tachycardia, tachypnea, and hypoxia. Initial laboratory findings were significant for leukocytosis, mildly elevated troponins to 37 ng/L. An ECG was obtained and showed ST-elevations in leads II, III, and aVF with Q waves present in leads III and aVF Image 1. Serial ECGs were obtained and demonstrated pseudo-normalization of the ST-elevations. Given the high risk of acute coronary syndrome, the patient was brought to the catheterization labs for a diagnostic coronary angiogram. However, results revealed non-obstructive coronary arteries. After the procedure, the patient reported worsening pain and nausea. Subsequent laboratory testing revealed elevated lipase to 2,484 U/L. Radiographic imaging revealed extensive pancreatic inflammation with fat stranding. Discussion Patients who have a history of anginal chest pain and present with ECG changes associated with right coronary artery stenosis raise concern for inferior wall myocardial infarction. In our case, the patient had a concern for myocardial infarction and was immediately brought to the catheterization lab. The results of the invasive procedure showed no obstruction of the coronary arteries. After further work-up, it was then determined that the patient had acute pancreatitis. ECG changes showing inferior myocardial infarction with acute pancreatitis have been noted to be an extremely rare presentation, with less than forty cases described in literature reviews. The mechanism for acute pancreatitis causing ECG changes is not clear; however, some mechanisms have been suggested including electrolyte abnormalities, proteolytic enzyme effects on myocardium, and coronary vasospasm. This case highlights the diagnostic challenge in which concurrent chest and epigastric pain with ECG changes would suggest myocardial injury. Although the likely outcome for patients with chest pain and ST elevations noted on ECGs would be catheterization, this case shows importances in concurrent work-up to raise awareness of alternative gastrointestinal etiologies that could be significant. This abstract is funded by: None