Editor – The case report by Wesson and colleagues (Clin Med April 2009 pp 186–7) purports to show an electrocardiographic pattern of a myocardial infarct produced by hypercalcaemia. The authors base this supposition on the absence of elevation in cardiac enzymes and the lack of ST elevation over the 36 hours before death. However they presented no previous electrocardiogram (ECG) for comparison nor an echocardiogram at the time of the abnormality, and they noted a history of coronary artery disease and left-sided heart failure.
I would suggest that, rather than postulate a pseudo-infarct due to elevated serum calcium, the correct diagnosis is unrelated to hypercalcaemia and simply represents the presence of a left ventricular aneurysm, with anterior wall Q waves and persistent ST elevation. This would fit with the history of left ventricular (LV) failure and angioplasty and would explain the negative enzymes. Although hypercalcaemia has, on rare occasions, been described as mimicking ST elevation due to its effect on the ST segment, there is no reason that it would cause the pathologic Q waves seen in leads V1 to V5. In contrast, pathologic Q waves with persistent ST elevation are typical of LV aneurysm.
The case was described as a ‘lesson of the month’. I believe that the lesson here is not the one that was presented but just the opposite. From the presented data one can conclude that common things occur most commonly, incomplete data (lack of prior ECG and no echocardiogram) may lead to incorrect diagnosis, and that even reputable journals allow information to be published that is inaccurate and misleading.