ECG Case 075

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

ECG 075a LITFL Top 100

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

Second ECG (pain free post transfer to tertiary cardiac centre)

ECG 075b LITFL Top 100
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

Articles

  • Yamaji H, Iwasaki K, Kusachi S, Murakami T, Hirami R, Hamamoto H, Hina K, Kita T, Sakakibara N, Tsuji T. Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. ST segment elevation in lead aVR with less ST segment elevation in lead V(1). J Am Coll Cardiol. 2001 Nov 1;38(5):1348-54. PMID: 11691506
  • Kosuge M, Ebina T, Hibi K, Morita S, Endo M, Maejima N, et al. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol. 2011 Feb 15;107(4):495-500 PMID: 21184992

TOP 150 ECG SERIES



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

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