Activate or Wait – 007

84 year-old woman from home with central chest pain following a fall. Background of hypertension and dyslipidaemia.

ETA 20 minutes to your tertiary centre.

Would you activate your cath lab/STEMI protocol?

ECG interpretation


Inferolateral STEMI

  • 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:

Takutsubo cardiomyopathy


  • 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

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

Further Information

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

Online resources


EKG Interpretation

MBBS (Hons), BMSci (Hons). Cardiology Registrar at Royal Perth Hospital in Perth, Australia. Graduate of The University of Western Australia in 2016 with Honours and completed Basic Physician Training with the RACP in 2021. Passion lie in cardiac imaging and electrophysiology.

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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