The annual estimated incidence for new and recurring STE is 550,000 and 200,000, respectively [1]. ST segment elevations (STE) are typically concerning for acute, transmural myocardial ischemia due to coronary disease. The differential diagnosis, however, includes several other important conditions that must be considered within the context of the patient. Common causes other than myocardial infarction include left ventricular hypertrophy, early repolarization, left bundle-branch block, ventricular aneurysm, pericarditis, and other inflammation adjacent to the heart [2]. Studies have shown between 51% and 85% of patients with both STE and chest pain have received non-infarction diagnoses [3,4].

In the absence of significant cardiac history or presentation, noncoronary causes should be considered. STE in cancer patients has been described previously in the literature. STE in these patients can occur transiently and in the presence or absence of cardiac symptoms or significant underlying coronary disease. Several case reports have described STE secondary to cardiac metastasis, including metastatic osteosarcoma [5].

We present a case of a patient with metastatic osteosarcoma and three transient STE patterns on electrocardiograms (ECG) in different coronary distributions that occur over 10 months.