Metastatic Lung Carcinoma Masquerading as ST Elevation Myocardial Infarction.

SESSION TYPE: Cardiovascular Student/Resident Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Neoplastic metastases to the heart and pericardium are more common than primary cardiac tumors. Cardiac metastasis occurs in as many as 22-31% of lung cancer patients. The majority experience pericardial metastasis while myocardial metastasis is described in 5.3-10.6% of patients. Often silent, these are rarely recognized prior to postmortem examination. ECG changes are rare and usually demonstrate non-specific ST and T wave abnormalities.CASE PRESENTATION: A 61 year old Caucasian male with a history of hypertension, hyperlipidemia and smoking was found to have multiple 1 mm ST-segment elevations in anterior and lateral ECG leads during a routine primary care visit. The patient reported mild cough symptoms but denied active chest pain. Serial cardiac enzymes remained negative. Left heart catheterization revealed normal coronary arteries with an apical filling defect on left Ventriculogram. Transthoracic echocardiography confirmed a large mass occupying the left ventricular apex. Further imaging with Cardiac MRI revealed enhancement on T2 series highly suggestive of neoplastic metastasis. A density in the left hemi-thorax was also noted. Chest CT Angiogram demonstrated mediastinal lymphadenopathy with a left hilar mass and post-obstructive left upper lobe collapse. Left pulmonary artery invasion and a filling defect in the cardiac apex were also noted. Fiber-optic bronchoscopic biopsy of the lung mass diagnosed moderately differentiated squamous cell lung carcinoma. Oncology was consulted for palliative chemo-radiation therapy. The patient continued to remain asymptomatic.DISCUSSION: Advanced lung cancer is the leading cause of cardiac metastasis. Cardiac involvement is also encountered in order of decreasing frequency with, lymphoma, breast, leukemia, melanoma, liver and colon cancer. Antemortem diagnosis is often challenging with most lesions discovered on autopsy. ECG changes similar to an acute myocardial infarction without cardiac marker elevation have rarely been reported in the past. Diagnostic evaluation using cardiac MRI and radionuclide imaging can be valuable in such cases.CONCLUSIONS: Direct myocardial invasion by malignant neoplasm is rare and often not clinically manifested. It can mimic acute Myocardial Infarction on ECG.1) Pomara C, Villani A, D'Errico S, Riezzo I, Turillazzi E, Fineschi V. Acute myocarditis mimicking acute myocardial infarction: a clinical nightmare with forensic implications. Int J Cardiol 2006; 112: 119-121.2) Hakeem A, Bhatti S, Fuh A, Mallof M, Stone C, Thornton F, et al. Viral myocarditis masquerading acute coronary syndrome (ACS) - MRI to the rescue. Int J Cardiol 2007; 119: e74- e76.DISCLOSURE: The following authors have nothing to disclose: Krish Ramachandaran, Sam Aziz, Stephen Phillips, Salman GoharNo Product/Research Disclosure InformationCarilion Clinic VTCSOM, Roanoke, VA.