How to manage ST segment elevation in a patient with Leptospirosis?

Management of ST Segment Elevation in Leptospirosis

Do not treat ST elevation in leptospirosis as a STEMI requiring reperfusion therapy unless there is clear clinical evidence of acute coronary syndrome with ongoing myocardial ischemia. ST elevation in leptospirosis typically represents myopericarditis or metabolic/electrolyte disturbances rather than coronary occlusion 1, 2.

Initial Diagnostic Approach

Distinguish Leptospirosis-Related ST Elevation from True STEMI

The critical first step is determining whether ST elevation represents acute coronary occlusion or leptospirosis-related cardiac involvement:

• Assess for ischemic symptoms: True STEMI presents with typical anginal chest pain radiating to neck, jaw, or left arm, whereas leptospirosis cardiac involvement typically presents with fever, myalgia, and non-specific chest discomfort 3, 1

• Evaluate the clinical context: Recent exposure history (water sports, occupational exposure, travel to endemic areas), presence of fever, jaundice, renal dysfunction, and thrombocytopenia strongly suggest leptospirosis rather than primary cardiac disease 4, 1

• Examine ECG pattern carefully: Leptospirosis commonly causes non-specific ventricular repolarization disturbances, first-degree AV block (44% of cases), and diffuse ST changes consistent with pericarditis, rather than the regional ST elevation pattern typical of coronary occlusion 1, 5, 2

Serial ECG Monitoring

• Obtain serial ECGs at 5-10 minute intervals to assess for dynamic changes that would suggest evolving myocardial infarction versus stable inflammatory changes 6

• Compare with prior ECGs if available to determine if ST elevation is new or chronic 3, 6

• Look for pericarditis pattern: Diffuse ST elevation with PR depression across multiple leads suggests pericarditis (common in leptospirosis) rather than territorial coronary distribution 2

Laboratory and Imaging Assessment

Cardiac Biomarkers

• Obtain cardiac troponins immediately, but recognize that troponin elevation in leptospirosis reflects myocarditis/pericarditis rather than coronary occlusion 3, 1

• Do not delay definitive management waiting for troponin results if clinical suspicion for either STEMI or severe leptospirosis is high 6

Bedside Echocardiography

• Perform urgent echocardiography to differentiate between regional wall motion abnormalities (suggesting coronary occlusion) versus global dysfunction or pericardial effusion (suggesting myopericarditis from leptospirosis) 6, 5

• Left ventricular function is typically preserved in leptospirosis despite ECG abnormalities, which helps distinguish it from STEMI 5

Leptospirosis-Specific Testing

• Send leptospira antibody titers and blood cultures immediately in patients with appropriate exposure history and systemic features 4

• Check for markers of severe leptospirosis: elevated bilirubin, elevated transaminases, acute renal failure, thrombocytopenia, and hypokalemia 1

Management Algorithm

If STEMI Cannot Be Excluded

When clinical suspicion for acute coronary occlusion remains high despite leptospirosis diagnosis:

• Activate STEMI protocols and proceed to emergency coronary angiography if the patient has ongoing ischemic symptoms with dynamic ST elevation, hemodynamic instability, or new regional wall motion abnormalities on echocardiography 6, 3

• Primary PCI is preferred over fibrinolysis in this scenario, as it provides definitive diagnosis and avoids bleeding risk from thrombolytics in a patient who may have leptospirosis-related thrombocytopenia 3, 1

If Leptospirosis-Related Cardiac Involvement Is Confirmed

Once acute coronary syndrome is excluded and leptospirosis cardiac involvement is established:

Antibiotic Therapy

• Initiate intravenous ceftriaxone 1g daily for 7 days as first-line treatment for severe leptospirosis, which is equally effective as penicillin G but offers once-daily dosing and broader spectrum 7

• Alternative: intravenous penicillin G 1.5 million units every 6 hours for 7 days if ceftriaxone is unavailable 7

Supportive Care

• Provide aggressive supportive care including fluid management, correction of electrolyte abnormalities (particularly hypokalemia), and monitoring for organ dysfunction 4, 1

• Consider intravenous corticosteroids in severe cases with marked systemic inflammation, though evidence is limited to case reports 4

• Continuous cardiac monitoring for arrhythmias, particularly given the high incidence of AV block and ventricular ectopy in leptospirosis 1, 5

Avoid Inappropriate Interventions

• Do not administer fibrinolytic therapy for ST elevation in confirmed leptospirosis without evidence of coronary occlusion, as thrombocytopenia is common and bleeding risk is substantial 1

• Do not give antiplatelet agents or anticoagulation unless true acute coronary syndrome is confirmed, given the bleeding risk from thrombocytopenia 1

Critical Pitfalls to Avoid

• Assuming all ST elevation requires reperfusion: The most dangerous error is reflexively treating leptospirosis-related ST elevation as STEMI, exposing patients to unnecessary bleeding risk from anticoagulation and antiplatelet therapy when thrombocytopenia is present 1

• Missing true STEMI in a leptospirosis patient: Conversely, patients with leptospirosis can develop concurrent acute coronary syndrome; maintain high suspicion if symptoms are typical for ischemia and ECG shows territorial rather than diffuse changes 3

• Delaying antibiotics for cardiac workup: Once leptospirosis is suspected, antibiotic therapy should begin promptly as it impacts mortality; cardiac evaluation should proceed in parallel, not sequentially 7

• Ignoring electrolyte abnormalities: Hypokalemia is common in leptospirosis and can exacerbate arrhythmias; aggressive correction is essential 1