Effoe V S, O'Neal W, Santos R, Rubinsztain L, Zafari A M
Atlanta Veterans Health Care System, Decatur, GA, USA.
Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA.
J Med Case Rep. 2019 Dec 30;13(1):387. doi: 10.1186/s13256-019-2315-1.
Chest pain associated with transient electrocardiogram changes mimicking an acute myocardial infarction have been described in acute pancreatitis. These ischemic electrocardiogram changes can present a diagnostic dilemma, especially when patients present with concurrent angina pectoris and epigastric pain warranting noninvasive or invasive imaging studies.
A 45-year-old African-American man with a history of alcohol use disorder presented to the emergency department of our institution with 36 hours of concurrent epigastric pain and left-sided chest pain radiating to his left arm and associated with nausea and dyspnea. On physical examination, he was afebrile; his blood pressure was elevated; and he had epigastric tenderness. His laboratory test results were significant for hypokalemia, normal troponin, and elevated serum lipase and amylase levels. Serial electrocardiograms for persistent chest pain showed ST-segment elevations with dynamic T-wave changes in the right precordial electrocardiogram leads, consistent with Wellens syndrome. He was immediately taken to the cardiac catheterization laboratory, where selective coronary angiography showed normal coronary arteries with an anomalous origin of the right coronary artery from the opposite sinus. Given his elevated lipase and amylase levels, the patient was treated for acute alcohol-induced pancreatitis with intravenous fluids and pain control. His chest pain and ischemic electrocardiogram changes resolved within 24 hours of admission, and coronary computed tomography angiography showed an interarterial course of the right coronary artery without high-risk features.
Clinicians may consider deferring immediate cardiac catheterization and attribute electrocardiogram changes to acute pancreatitis in patients presenting with angina pectoris and acute pancreatitis if confirmed by normal cardiac enzymes and elevated levels of lipase and amylase. However, when clinical signs and electrocardiogram findings are highly suggestive of myocardial ischemia/injury, immediate noninvasive coronary computed tomography angiography may be the best approach to make an early diagnosis.
急性胰腺炎患者可出现与短暂心电图改变相关的胸痛，这些改变酷似急性心肌梗死。这些缺血性心电图改变可能会带来诊断难题，尤其是当患者同时出现心绞痛和上腹部疼痛，需要进行无创或有创影像学检查时。
一名45岁有酒精使用障碍病史的非裔美国男性因同时出现36小时的上腹部疼痛和左侧胸痛（放射至左臂）并伴有恶心和呼吸困难，就诊于我院急诊科。体格检查时，他体温正常；血压升高；有上腹部压痛。他的实验室检查结果显示低钾血症、肌钙蛋白正常、血清脂肪酶和淀粉酶水平升高。针对持续性胸痛的系列心电图显示，右胸前导联有ST段抬高及动态T波改变，符合Wellens综合征。他立即被送往心脏导管实验室，选择性冠状动脉造影显示冠状动脉正常，但右冠状动脉起源于对侧窦。鉴于其脂肪酶和淀粉酶水平升高，该患者接受了静脉补液和疼痛控制治疗急性酒精性胰腺炎。他的胸痛和缺血性心电图改变在入院后24小时内消失，冠状动脉计算机断层扫描血管造影显示右冠状动脉走行于动脉间，无高危特征。
对于同时患有心绞痛和急性胰腺炎的患者，如果心脏酶正常且脂肪酶和淀粉酶水平升高得以证实，临床医生可考虑推迟立即进行心脏导管检查，并将心电图改变归因于急性胰腺炎。然而，当临床体征和心电图表现高度提示心肌缺血/损伤时，立即进行无创冠状动脉计算机断层扫描血管造影可能是早期诊断的最佳方法。
