Activate or Wait – 005

• ST elevation in lead V1-V3 (>2mm in V2)
• Reciprocal ST depression in inferior leads, most notable in lead III
• Hyperacute T-waves in V2-V5

This ECG demonstrates more subtle findings of anterior STEMI, however the clinical presentation should raise our index of suspicion.

Note that although the measurement of 2mm in V2 is mentioned and meets STEMI “criteria”, these criteria are not entirely specific or sensitive for acute occlusion myocardial infarction. In early presentations, reciprocal ST depression may be the most prominent finding suggesting evolving infarction. These patients will not meet traditional criteria but will still benefit from emergent angiography. Likewise, many patients with benign early repolarisation have ST elevation meeting ECG STEMI criteria.

Key Finding:

Findings:

• Left Main Coronary Artery – short. Widely patent.
• Left Anterior Descending Coronary Artery – type III vessel. 50% proximal stenosis. Occluded from mid-vessel. Thrombotic. Culprit.
• Left Circumflex Coronary Artery – large calibre vessel. Mild disease.
• Right Coronary Artery – medium calibre vessel. Dominant. Moderate mid vessel disease.
• Left Ventriculogram – systolic function 45% anterolateral hypokinesis.

Recommendation:

Occluded LAD (culprit). Proceeded to PCI of mid LAD.

1. Dual antiplatelet therapy for at least 12 months, aspirin lifelong.
2. Aggressive cardiovascular risk factor management.
3. Smoking cessation.
4. Admit CCU.

Further reading

• Burns E, Buttner R. Anterior Myocardial Infarction. LITFL
• Burns E, Buttner R. T wave. 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.