Difficulties in electrocardiographic diagnosis of hyperkalemia and acute coronary syndrome: clinical case

BACKGROUND: Clinical practice testifies to the difficulties in diagnosing hyperkalemia according to electrocardiographic (ECG) criteria during the primary contact between the doctor and the patient. This leads to the establishment of alternative diagnoses, particularly acute coronary syndrome, a delay in the implementation of measures aimed at lowering the blood potassium levels and a possible adverse outcome.

CLINICAL CASE DESCRIPTION: The article presents the clinical observation of a patient with severe hyperkalemia in the background of acute renal injury caused by mesenteric thrombosis, with ECG changes in the form of high-amplitude T wave in leads V₂–V₆ and induced non-sustained ventricular tachycardia. Considering the patient’s history of coronary heart disease, ECG data (high-amplitude T wave in leads V₂–V₆) were regarded as acute coronary syndrome with ST segment elevation. According to emergency indications, the patient underwent coronary angiography and endoprosthetics of the left circumflex artery (stenosis 99%). Upon further examination, levels of biomarkers of myocardial necrosis were slightly increased, which confirmed the established preliminary diagnosis and hyperkalemia. However, 6 h after hospitalization, the patient died. A subsequent autopsy revealed a contradiction between the clinical path and anatomical diagnosis.

CONCLUSION: This case reveals the complexity of the differential diagnosis of changes in the T wave and ST segment. Failure to promptly determine the underlying cause of these ECG changes in the presented case led to an inaccurate management strategy that negatively affects the prognosis.