Activate or Wait – 007

Interpretation

• Diffuse ST elevation globally in leads I, II, III, aVF, V2-V6
• Reciprocal ST depression in aVR
• Q-waves in leads II, III, aVF, V4-V6

The presence of Q-waves suggest this may be a late presentation infarct, however timing of symptoms is not available to us and as such a CODE STEMI activation is appropriate.

However, the clinician should note that the history of a fall and subsequent chest pain is atypical. This combined with the diffuse nature of ST elevation could suggest an alternative cause of presentation.

The patient was taken for emergent angiography upon arrival.

Key Finding:

Findings:

• Left Main Coronary Artery – large calibre, very short.
• Left Anterior Descending Coronary Artery – medium calibre, calcified moderate 40% disease at bifurcation of D1.
• Left Circumflex Coronary Artery – non-dominant, medium calibre, mild disease.
• Right Coronary Artery – dominant, medium calibre, moderate 60% calcified eccentric disease in mid vessel.
• Left Ventriculogram – Apical hypo-akinesis with basal hyperkinesis

Plan:
Takotsubo cardiomyopathy with moderate, nonobstructive coronary artery disease.
1. Ongoing medical therapy and risk factor modification
2. Admit to CCU

Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy, or ‘broken-heart syndrome’, describes transient dyskinesis of the left ventricle wall, often occurring in the context of severe emotional or physical stress. It presents with ischaemic chest pain, a troponin elevation and ECG changes that mimic a STEMI.

Coronary angiography is thus necessary to differentiate the conditions.

It is thought to be caused by a catecholamine surge and microvascular spasm that leads to left ventricular dyskinesis. In this case, it is likely the fall precipitated significant emotional and physical stress that lead to the event. This condition is managed medically and in most cases resolves with good outcomes.

Further reading

• Buttner R, Burns E. Takotsubo Cardiomyopathy. LITFL
• Burns E, Buttner R. The ST Segment. 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.