When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT

One Overlooked Pitfall on TMT

  • Dmitri Muhammad Rifanda General Practitioner, Jakarta Heart Center, Jakarta, Indonesia
  • M. A. L. Parama General Practitioner, Jakarta Heart Center, Jakarta, Indonesia
  • Teuku Muhammad Haykal Putra Cardiologist, Jakarta Heart Center, Jakarta, Indonesia
  • Wishnu Aditya Widodo Cardiologist, Jakarta Heart Center, Jakarta, Indonesia
DOI: https://doi.org/10.30701/ijc.1197
Keywords: Treadmill Test; Hypokalemia; Coronary artery disease

Abstract

When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT

 

Background:

Particular ischemic process that portrayed in Electrocardiogram (ECG) changes bear similar depiction to different conditions, one of them is hypokalemia. On the other hand, Treadmill Test (TMT) has been used for decades for risk stratifying and diagnosing coronary artery disease as a non-invasive, safe and affordable screening test. However, using ECG changes as interpretation, TMT could have incidence of false positive results reported in various conditions, one of which is hypokalemia. The aim is to report a case of positive ischemic response resemblance in TMT of patient with severe hypokalemia.

 

Case Illustration:

A-43-years-old female with history of unstable angina pectoris with risk factors of diabetes mellitus and hypertension underwent several examinations. Computed Tomography Coronary Angiography (CTCA) showed a 60% stenosis lesion in Left Anterior Descending (LAD) coronary artery. Within 3 minutes of TMT the ECG showed ST-segment depression in lead II, III, aVF, V1-V6 and prominent elevation in lead aVR. Fear of left main coronary artery occlusion, the test was terminated and the patient was immediately planned for urgent Percutaneous Coronary Intervention (PCI). The result indicated non-significant coronary lesion. Potassium concentration of 1.87 mmol per liter and troponin levels were normal. Unbeknownst before, the patient had multiple episodes of vomiting for a whole day and felt dehydrated prior to the TMT. Patient then treated for potassium implementation and discharged uneventfully.

 

Conclusion:

Hypokalemia could induce widespread ST-Segment depression or ST-Segment elevation in right limb lead. Peculiarly in context of stress testing or accompanied with chest pain, it is difficult to differentiate ECG changes in hypokalemia with true myocardial ischemia. Hypokalemia should be considered when TMT result is not concordance with true myocardial ischemia.

 

Downloads

Download data is not yet available.

References

1. Attar, A., Mehrzadeh, A., Foulad, M., Aldavood, D., Fallahzadeh, M. A., Assadian Rad, M., & Khosropanah, S. (2017). Accuracy of exercise tolerance test in the diagnosis of coronary artery disease in patients with left dominant coronary circulation. Indian Heart Journal, 69(5): 624-627.
2. Vilcant V, Zeltser R. Treadmill Stress Testing. 2021 Jul 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29763078.
3. Bittencourt, M. S., Hulten, E., Polonsky, T. S., Hoffman, U., Nasir, K., Abbara, S., di Carli, M., & Blankstein, R. (2016). European Society of Cardiology–Recommended Coronary Artery Disease Consortium Pretest Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score. Circulation, 134(3): 201-211.
4. Kharabsheh, S. M., Al-Sugair, A., Al-Buraiki, J., & Farhan, J. (2006). Overview of Exercise Stress Testing. Annals of Saudi Medicine, 26(1):1-6.
5. Fitzgerald, B. T., Scalia, W. M., & Scalia, G. M. (2019). Female False Positive Exercise Stress ECG Testing – Fact Versus Fiction. Heart, Lung and Circulation, 28(5):735-741.
6. Wang X, Han D, Li G. Electrocardiographic manifestations in severe hypokalemia. Journal of International Medical Research. 2018;48(1):030006051881105.
7. Chua, C. E., Choi, E., & Khoo, E. Y. H. (2018). ECG changes of severe hypokalemia. QJM: An International Journal of Medicine, 111(8):581-582
8. Diercks, D. B., Shumaik, G. M., Harrigan, R. A., Brady, W. J., & Chan, T. C. (2004). Electrocardiographic manifestations: electrolyte abnormalities. The Journal of Emergency Medicine, 27(2):153-160
9. Petrov, D., Sardovski, S., & Milanova, M. (2012). Severe Hypokalemia Masquerading Myocardial Ischemia. Cardiology Research, 3(5):236-238.
Published
2022-09-17
Views & Downloads
Abstract views: 3310   
Fulltext (PDF) downloads: 1378   
How to Cite
Rifanda, D., Parama, M. A. L., Putra, T., & Widodo, W. (2022). When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT. Indonesian Journal of Cardiology, 43(1), 30-6. https://doi.org/10.30701/ijc.1197
Issue
Vol 43 No 1 (2022): Indonesian Journal of Cardiology: January - March 2022
Section
Case Reports

Copyright (c) 2022 Indonesian Journal of Cardiology

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Authors who publish with this journal agree to the following terms:

    • Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
    • Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
    • Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).