Activate or Wait – 006

• ST elevation and hyperacute T waves (HATW) laterally in leads V4-V6
• There is also some subtle ST elevation in V3
• Q-waves in aVL, V1-V4
• Have a close look at the T wave in aVL — these authors also consider this to be a HATW. Remember, the area under the curve is more important than the height in HATW, which often present initially as wide, bulky T waves.

Note the evolution of changes between the first and second ECGs. ST segments have elevated further in lateral leads, and Q-waves in V1-V3 have deepened and extended to V4 and aVL, indicating progressive ischaemia in this territory.

Key Finding:

Findings:

• Left Main Coronary Artery – mild irregularities.
• Left Anterior Descending Coronary Artery – mild irregularities.
• Left Circumflex Coronary Artery – large calibre vessel. Non-dominant. 99% stenosis in mid vessel. culprit.
• Right Coronary Artery – large calibre vessel. dominant. Mild irregularities.

Plan:

Single vessel coronary artery disease. 99% stenosis left circumflex. Successful percutaneous coronary intervention to mid left circumflex with drug eluting stent

1. Dual antiplatelet therapy for 12 months. Lifelong aspirin.
2. Ongoing cardiovascular risk factor management.
3. Smoking cessation.
5. Admit CCU.

Further reading

• Burns E, Buttner R. Lateral STEMI. LITFL
• Nickson C. STEMI Management. LITFL
• Burns E, Buttner R. Q-wave. 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.