Activate or Wait – 002

• Concordant ST elevation in leads V2-4, I and aVL — note the presence of right bundle branch block (RBBB)
• Reciprocal concordant ST depression in inferior leads II, III, aVF
• Evolving Q waves in aVR, aVL and V1-2

Concurrent left anterior fascicular block (left axis deviation) in this case indicates a bifascicular block. Although this may be pre-existing, a new bifascicular often accompanies a proximal LAD occlusion, as the right bundle branch and left anterior fascicle are supplied by a proximal septal branch of the LAD.

ST elevation in anterior leads here is prominent, however in the presence of a right bundle branch block, any degree of concordant ST elevation is highly concerning for occlusion myocardial infarction (OMI).

Key finding:

Findings:

• Left Main Coronary Artery -Normal
• Left Anterior Descending Coronary Artery – 40% after LADD2
• Left Circumflex Coronary Artery – 30% proximal
• Right Coronary Artery -Dominant, irregular
• Left Ventriculogram -anterior hypokinesis with mild LV impairment

Recommendation:
Likely plaque rupture LAD with thrombus but no occlusive disease

1. Medical management with 12 months dual antiplatelet therapy
2. Aggressive cardiovascular risk factor management.
3. Admit to CCU

Further reading

• Burns E, Buttner R. Anterior Myocardial Infarction. LITFL
• Nickson C. STEMI Management. LITFL

Online resources

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.