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ECG Case 075

Previously well 70 year old man presents to peripheral hospital with central chest pain and diaphoresis

ECG 075a LITFL Top 100
ECG 1

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

Rate:

  • 102

Rhythm:

  • Sinus

Axis:

  • LAD (-30 to -60)

Intervals:

  • PR – Prolonged (200 – 240ms)
  • QRS – Normal (80ms) 
  • QT – 440ms (QTc Bazett 310ms)

Segments:

  • ST Elevation aVR (3-4 mm) V1 (3mm) V2 (2mm) 
  • ST Depression I, II, aVF, aVL, V4-6

Additional:

  • Notched p wave in lead II, possible biphasic P wave in V1
  • Poor r wave progression

Interpretation:

  • Most marked abnormality is ST elevation in aVR, V1-2, with ST Depression I, II, aVF, aVL, V4-6
  • Also 1st Degree AV block and possible left atrial enlargement (p mitrale)
  • This pattern is most consistent with a LMCA occlusion (STE aVR >/= V1) 
  • LMCA occlusion associated with a high mortality (aVR STE>1.5mm up to 70% mortality)
  • Could also be proximal LAD lesion or severe 3-vessel disease

Management

  • Urgent liaison with cardiology is required
  • Need to discuss reperfusion therapy based on available resources / local policies
  • Consideration of likelihood of requiring CABG is needed as this may affect initial drug therapy, particularly clopidogrel or prasugrel due to increased incidence of post operative bleeding

ECG 2

ECG 075b LITFL Top 100
ECG 2: pain free post transfer to tertiary cardiac centre
ECG INTERPRETATION

Key features:

  • ST Elevation V1-2 (1mm)
  • ST Depression I, aVL, V5-6

Interpretation:

  • ST Elevation & Depression Resolving when compared with ECG 1

What happened next ?

  • Patient was reviewed and admitted by cardiology team
  • Planned for urgent angiography
  • Pt declined intervention
  • Re-presented with APO and cardiogenic shock

FURTHER READING

Life in the Fast Lane

Dr Smith’s ECG Blog

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TOP 100 ECG Series


Emergency Medicine Specialist MBChB FRCEM FACEM. Medical Education, Cardiology and Web Based Resources | @jjlarkin78 | LinkedIn |

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