Heart disease remains the leading cause of mortality in the United States, accounting for about one quarter of all deaths in 20131. Acute ischemic heart disease is a major subpopulation of this group, and typically presents with characteristic electrocardiographic (EKG) changes. The most concerning of these findings are ST-elevations, as ST Elevation Myocardial Infarction (STEMI) typically indicates the need for emergent reperfusion therapy because 30-day mortality of untreated STEMI is approximately 10-15% versus 5% in treated cases2. As a result, clinicians are taught to recognize the symptoms and signs of myocardial ischemia and STEMI in order to achieve timely reperfusion either via thrombolytic therapy within 30 minutes or percutaneous coronary intervention within 90 minutes.

However, ST-elevations may result from etiologies other than acute ischemia, and can be secondary to other acutely life-threatening pathologies or relatively benign, subacute causes. For example, ventricular aneurysms resulting from prior myocardial infarction and pericarditis can result in ST-elevation on EKG. Intracranial hemorrhage or stress (takotsubo) cardiomyopathy can also present with ST-elevations, theorized to be the result of increased catecholamines. Left ventricular hypertrophy, a sequela of poorly controlled hypertension, can also lead to J point elevations mimicking STEMI3,4. Here we review a case of unusual ST-elevation in a patient with oropharyngeal squamous cell carcinoma metastatic to the heart.