Activate or Wait – 010
38-year-old male with left arm pain, shortness of breath, and dizziness. BP 105/60.
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ECG interpretation
Inferior STEMI
- Marked ST elevation and hyperacute T waves (HATW) in leads II, III, aVF and I
- Reciprocal ST depression in V1-3 and aVR
- Q waves in leads I, II
- T waves in V4-6 are broadened also resembling HATW
- Borderline first degree AV block
Notably, marked ST depression in V2 > V1 is concerning for right ventricular infarction. These patients are preload sensitive and can develop severe hypotension in response to nitrates.
Outcome
Key finding:
RCA occlusion
Findings:
- Left Main Coronary Artery – mild irregularities
- Left Anterior Descending Coronary Artery – mild irregularities
- Left Circumflex Coronary Artery – mild irregularities
- Right Coronary Artery – dominant and occluded mid-vessel
- Left ventriculogram – mild-moderate systolic dysfunction
Proceeded to PCI to RCA.
Recommendation:
- Dual antiplatelet therapy – aspirin 100mg + ticagrelor 90mg BD for 12 months. Aspirin 100mg daily for life
- Ongoing aggressive cardiovascular risk factor management
- Admit CCU
Clinical Pearls
- ECG features of RV infarction can be subtle and easily missed. Examine closely for ST depression in V2 relative to an isoelectric ST segment in V1. Diagnosis is confirmed by the presence of ST elevation in right-sided leads (V3R-V6R)
- These patients are preload dependent and can develop severe hypotension in response to nitrates
References
Further reading
- Buttner R, Burns E. Inferior STEMI. LITFL
- Buttner R, Burns E. Right Ventricular Infarction. 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.
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.