Massive pulmonary embolism with ST-elevation in the inferior leads and other interesting ECG findings

Introduction: Pulmonary embolism is associated with many ECG findings, most of which are non-specific and most can be explained by the sudden severe increase in the right ventricular afterload leading to dysfunction, hypoperfusion, dilation and in rare very severe cases to ischemic injury. Many case reports described patients presenting with massive pulmonary embolism and very rare atypical ECG findings especially ST-segment elevation in the anteroseptal leads (V1-V4). Case presentation: We present a case of a 73-year old African American male who suffered from a massive pulmonary embolism with interesting ECG findings mainly ST-segment elevation in the inferior leads mimicking Inferior wall myocardial infarction. To our knowledge, this is the first case of ST-elevation in the inferior leads in the setting of a massive PE. Conclusion: The most likely explanation to the case is that the associated cardiac injury is multifactorial. Severe right ventricular dilation with significant increase in wall tension and oxygen consumption, sudden coronary hypoperfusion caused by the sudden drop in the right and left ventricular output, hypoxia caused by the massive PE and finally possible coronary spasm caused by hypoxia and increased right heart pressure might all have contributed to inducing the acute right ventricular ischemia which showed as ST-segment elevation in the inferior leads and an elevation in cardiac enzymes.