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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.

3794
Would you activate your cath lab/STEMI protocol?

ECG interpretation

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 for occlusion myocardial infarction. This combined with the diffuse nature of ST elevation could suggest an alternative cause of presentation.

Outcome

The patient was taken for emergent angiography upon arrival.

Key Finding:

Takutsubo cardiomyopathy

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

Clinical Pearls
  • Takotsubo cardiomyopathy, or ‘broken-heart syndrome’, describes transient dyskinesis of the left ventricular 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 necessary to differentiate the two conditions

References

Further reading

Online resources


ACTIVATE or WAIT

EKG Interpretation

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

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.

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