EXTRA COPY — ECG Blog #540: It Doesn't "Fit" ...- EXTRA COPY

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Figure-1: The initial ECG in today's case — obtained from an adult with frequent "palpitations". (To improve visualization — I've digitized the original ECG using PMcardio).

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Figure-2: XXX

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Figure-3: XXX

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Acknowledgment: My appreciation to Paul Carr and Nataliya Szozda (from Toronto, Canada) for contributing this case.

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From Paul Carr

Paul Carr <paul.carr@medportal.ca>  (7/13/2026)

TITLE: — It Does Not "Fit" Clinical —

ME TO ACKNOWLEDGE: — Paul Carr and Dr. Nataliya Szozda (both from Toronto, Canada) 

 

This case is from a rural hospital with no cath lab or stroke thrombolysis capacity.

A 59 year old female was brought by ambulance to the emergency department. She was at a spa and while getting out of the hot tub suddenly became confused and unable to speak. She subsequently had clonic movements and profuse diaphoresis. She was placed in a position of safety.

 

On EMS arrival patient was confused and "post ictal" with ongoing diaphoresis. During transportation she became agitated and combative requiring sedation with midazolam. During transport the monitor showed ECG changes concerning for "STEMI" and so they diverted to my local hospital rather than preceding directly to the nearest stroke centre. On arrival patient was not responsive.

 

The nearest interventional cardiologist was paged and his concern was that with the story not fitting occlusion MI, it was important to work up for other etiologies before considering any medical intervention for possible acute MI.

 

The nearest stroke centre also had interventional cardiology and the stroke team there agreed to take the patient emergently "code stroke".

 

While patient was in transit the initial high sensitivity troponin was 400 (upper limit of normal for our assay is 20).

 

At the stroke centre the patient was found unfortunately to have a necrotic ring enhancing mass with significant surrounding edema favoured to represent a tumour. I do not have a follow-up ECG but my understanding is these ST elevations normalized over 1-2 hours.

 

Paul Follow-Up !!!!

Survived neurologically intact. Now they think might be necrotic transformation of previous stroke rather than tumour. Cardiologist opined may be Takotsubo. Repeat troponin was unchanged.

 

Just saw that they did do a Cath and pristine coronaries with mid-type typical Takotsubo wall motion abnormality.

SSmith! "Clinical does not "fit" OMI. These cases tell you everything you need to know to interpret your case!

Dec. 20, 2021 CASE

https://drsmithsecgblog.com/collapse-ventricular-tachycardia/

 

Feb. 20, 2025 CASE

https://drsmithsecgblog.com/acute-coma-then-sudden-pea-arrest-in-2/

MY REPLY to PAUL — I wrote Steve back the following: THANKS Steve! My Comment on the 2nd case you sent (from Feb. 20, 2025) relates to a subarachnoid hemorrhage causing the pseudo-MI pattern. I hadn’t been aware of brain tumor doing the same, but as per your 1st case — a simple MI should not result in a non-responsive patient — and no flow to the heart as well as the brain + greatly increased catecholamines might raise Troponin and produce bizarre ECG changes that in a patient with CP would say S. Afr. Flag .. — but which in a comatose patient say CNS catastrophe and NO MI. THANK YOU = “Clinical does not fit OMI!” —

 

PAUL — So yes, I DO want to write up this case! I like to acknowledge people — so should I say that the case is from Paul Carr from Toronto, Canada? — or if you prefer, the case can be anonymous — JUST LET ME KNOW! It may be a little while before I publish it as I have other cases to go in front of it.

Otherwise — My wife and I just went on a Tauck tour to Canada's eastern "Capital Cities" and Toronto was our first stop. GREAT CITY! I love the unique skyline! We went up the CN Tower and toured the city. Other stops on the tour were Niagara Falls (Canadian side) — Ottawa, Montréal, Québec — GREAT country, wonderful and friendly people who amazingly still like us Americans after all the mess that our current administration continues to cause (very embarrassing to me!)

Let me know if you find out anything else? Did the patient survive?
I'll let you know when I publish this — :)

 

Paul Follow-Up !!!!

Survived neurologically intact. Now they think might be necrotic transformation of previous stroke rather than tumour. Cardiologist opined may be Takotsubo. Repeat troponin was unchanged.

 

Just saw that they did do a Cath and pristine coronaries with mid-type typical Takotsubo wall motion abnormality.

 

 

MY REPLY (7/14/2026):

Thanks for the clinical & ECG follow-up! Cath very helpful that it ruled out coronary disease and confirmed Takotsubo. That said — although Takotsubo can definitely mimic an acute MI (!) — as Takotsubo evolves, you'll usually see a more prolonged QTc than what we see here ... so would be GREAT if you could find out #1) How much time passed between these 2 ECGs that you have sent me — and #2) Any chance you could check to see if a final ECG was done? (looking to see if the T wave inversion with long QTc finally developed .... GREAT CASE with review of Takotsubo here. THANKS again! — :) Ken

https://ecg-interpretation.blogspot.com/2024/10/ecg-blog-456-woman-with-chest-pain-from.html

 

P.S. You say "Ontario, Canada" — but for "symmetry", is it OK if I say both you and Dr. Szozda are from Toronto, Canada? 

 

P.P.S. It may be a little while until I publish this as I have other cases to go before — but I'll definitely let you know when I do publish it — :)

 

PAUL REPLY (on 7/16/2026):

Thanks as always. Yes Toronto Canada for both is great. There was only about 4 hours between ECGs I believe and I will look for a discharge ECG for completeness. Probably best to have some time before publication to help with anonymity of the case anyway. All the best, Paul

PAUL's COMPLETE CASE !!!!
Hi, Ken, This is Paul Carr writing. Had a very interesting case yesterday I wanted to share in case you wanted to use for the blog.

 

This case is from a rural hospital with no cath lab or stroke thrombolysis capacity.

 

A 59 year old female was brought by ambulance to the emergency department. She was at a spa and while getting out of the hot tub suddenly became confused and unable to speak. She subsequently had clonic movements and profuse diaphoresis. She was placed in a position of safety.

 

On EMS arrival patient was confused and "post ictal" with ongoing diaphoresis. During transportation she became agitated and combative requiring sedation with midazolam. During transport the monitor showed ECG changes concerning for "STEMI" and so they diverted to my local hospital rather than preceding directly to the nearest stroke centre.

 

On arrival patient was not responsive. She was met in the ambulance bay where a formal ECG showed concerning elevation in I and aVL, disproportionately large T waves in I, and reciprocal depression maximal in lead III.

 

The nearest interventional cardiologist was paged and his concern was that with the story not fitting occlusion MI it was important to work up for other etiologies before considering any medical intervention for possible acute MI.

 

The nearest stroke centre also had interventional cardiology and the stroke team there agreed to take the patient emergently "code stroke".

 

I had a broad differential and agreed with the consultant recommendations. Near the top for me was acute aortic syndrome involving the left main coronary with embolic stroke so we did not give any antiplatelet or anticoagulation.

 

While patient was in transit the initial high sensitivity troponin was 400 (upper limit of normal for our assay is 20).

 

At the stroke centre the patient was found unfortunately to have a necrotic ring enhancing mass with significant surrounding edema favoured to represent a tumour. I do not have a follow-up ECG but my understanding is these ST elevations normalized over 1-2 hours.

 

It is important to remember that history is just as important as the ECG itself and that we need to keep an open mind and at least consider a thorough differential for all cases.

 

I'm curious to see what QOH would make of that ECG and also for your expert opinion on the case.

 

Best wishes,

Paul