The apex talks…cardiac metastasis mimicking st segment elevation myocardial infarction

Background Cardiac metastases are more common than primary cardiac malignancy. Typical presentation includes arrhythmias. Echocardiography is the initial imaging test for the detection of cardiac metastasis, although echocardiography with contrast agent, cardiac magnetic resonance and computed tomography may be helpful. Herein we described a case of cardiac metastasis with EKG mimicking acute coronary syndrome. Case summary A 78-year-old man with a recent diagnosis of lung squamous cell carcinoma was referred to our cardiology department for marked ECG abnormalities (ST segment elevation in V2-V4) in the absence of ischemic symptoms. A transthoracic echocardiogram showed an isoechoic mass at the left ventricular apical segments apparently incorporating the myocardial wall. A contrast echocardiography with Sonovue revealed a late uptake of the contrast. Cardiac magnetic resonance showed an ovular image in the para-apical area consistent with a secondary lesion. Coronary angiography excluded significant stenosis. Finally, the patient was transferred to the oncology department for specific management. Discussion Our case describes a cardiac metastasis with EKG mimicking acute coronary syndrome. This finding is not uncommon among these patients. EKG findings of myocardial ischemia or injury, particularly localized and prolonged ST elevation, in the absence of ischemic symptoms have been reported in previous studies as high specificity for cardiac metastasis in patients with malignancy. We want to highlight the importance of using all cardiac imaging techniques in the differential diagnosis of cardiac masses; cardiac magnetic resonance certainly represents the gold standard but a simple echocardiography with ultrasonic enhancing agent is definitely helpful.