ECG Case 075

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

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

Life in the Fast Lane

• ECG Library – ST Elevation in aVR
• ECG Library – Left Atrial Enlargement
• More case reviews of STE in aVR: Cardiac Megacode; Another Widow maker

Dr Smith’s ECG Blog

• Smith S. Deep and widespread ST depression signifies high risk coronary lesion. 2010
• Smith S. ST elevation in aVR, with widespread ST depression. 2011

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
• 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