Reversal of low voltage and infarction pattern on the surface electrocardiogram after renal hemodialysis for pulmonary edema

A case is presented in which markedly low surface electrocardiographic (ECG) voltage and an infarction pattern are rapidly reversed with renal hemodialysis for pulmonary edema. A patient presenting with QRS voltages below 0.1 mV in all the limb and augmented limb leads and a waveform pattern suggestive of an anterior and inferior myocardial infarction experienced a dramatic increase in voltage and a reversal of the infarction pattern after dialysis. A hypothesis is proposed in which alterations in chest wall impedance and in electrolytes are involved in the ECG changes resulting from dialysis. This case illustrates one source of diagnostic error, and that dialysis may result in large, rapid changes in the ECG. Diagnostic errors may be avoided by obtaining serial ECGs in patients undergoing dialysis.