Pseudo-myocardial infarction versus pseudo-pseudo-myocardial infarction.

Pseudo-Pseudo-Myocardial Infarction To the Editor: Hung and colleagues1 present a very important example of a pseudo-infarction pattern presumably related to pancreatitis, one of several clinical situations in which thrombolytic therapy is either not indicated or contraindicated. I am intrigued by the pattern of the bizarre T waves in the limb leads and wonder if part or all of this phenomenon is artifact. The T waves are of unusually abrupt onset and offset. They are of greatest magnitude in leads I, II, and aVR. Lead III, however, appears to be isoelectric to this postulated artifact but not to the T wave that is 1 to 2 mm in height and gently (ie, normally) inscribed. The artifact is of about half the magnitude and is approximately equal in leads aVL and aVF. The precordial leads reflect the artifact, which is increasing the apparent height of the actual T waves, which appear inscribed on top of the artifactual elevation. The initial j-point or ST elevation in the precordial leads appears real, in that the onset is before that of the artifact in the limb leads but difficult to interpret in the presence of the artifact. Because the artifact is of greatest magnitude in the 3 leads that have a right arm electrode attachment in common, could there have been motion of the electrode or its connections leading to this artifact? For instance, the timing of onset, duration, and contour of the artifact seem compatible with an arterial pulse wave altering skin contact with each heart beat. It would be important to know whether the bizarre T waves in the limb leads and the terminal T wave elevation in the precordial leads all resolved slowly or whether there was an abrupt change that would favor artifact. The follow up electrocardiograms are essential to resolving this issue. Finally, whenever an unusual, bizarre, or unexplainable electrocardiographic finding is detected, it is most helpful to repeat the electrocardiogram personally, with a machine that is known to be trustworthy, to confirm that the findings are indeed real.