P1945 - In With ACS, Out With HCC

Grace E. Kim, MD¹, Zachary Wynne, MD¹, August Kunkel, MD¹, MIchael Miller, MD^2
1University of Maryland Medical Center, Baltimore, MD; ²University of Maryland School of Medicine, Baltimore, MD

Introduction: Acute coronary syndrome (ACS) is one of the most common presenting symptoms in the US accounting for more than 1 million hospitalizations yearly. Nonetheless, ST elevation without ACS is rare. Here we describe an atypical presentation of a patient with ST elevation on electrocardiogram (EKG) that was suspicious for ACS, but instead was found to have a newly diagnosed hepatocellular carcinoma (HCC).

Case Description/Methods: A 64-year-old man with a history of hypertension and chronic hepatitis C presented with a month of exertional dyspnea without chest pain. He denied orthopnea, edema, or palpitations. His EKG was notable for 1mm ST elevations in leads II, III, and AVF with elevated troponin-T at 18 ng/L (references range < =10, Figure 1a). Interventional cardiology was consulted but because of lack of chest pain, he was recommended for conservative management.

Upon further questioning, the patient endorsed a considerable weight loss with negative personal or family history of cancer or cardiac disease. Physical exam revealed a cachectic man with multiple seborrheic keratoses in the back suggestive of Leser-Trélat. He also had a 7-cm firm, nontender, pulsatile mass in the epigastrium that the patient was unaware of until it was identified on exam.

Notable laboratory values included creatinine of 2.38 mg/dL (0.9-1.3), aspartate aminotransferase 67U/L (0-37), and hemoglobin 9.1g/dL (12.5-16.3). ST elevation and troponin-T resolved a few hours later. A non-contrast computed tomography (CT) of abdomen and pelvis showed multiple heterogeneous hypoattenuating lesions with regional lymphadenopathy. Triple phase abdominal CT showed two heterogeneous masses with the larger one in the left hepatic lobe that was palpated on exam (Figure 1b). Alpha-fetoprotein (AFP) was 696.8 ng/mL (0-6). He was diagnosed with hepatocellular carcinoma and established care with oncology.

Discussion: Though uncommon, noncardiac conditions can mimic STEMI, including gastric distension, cholecystitis, and pancreatitis. In the case of our patient, direct compression from the HCC was the most likely etiology of the EKG changes promoting visceral-cardiac reflexes; this is based upon the absence of chest pain or dynamic EKG changes otherwise anticipated with true ACS. Leser-Trélat seen on physical exam prompted a more thorough oncological history taking. To our knowledge, this is the first description of HCC leading to ST-elevation. This case highlights the importance of a comprehensive history and physical without anchoring bias.



Disclosures:


Grace E. Kim, MD¹, Zachary Wynne, MD¹, August Kunkel, MD¹, MIchael Miller, MD². P1945 - In With ACS, Out With HCC, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.