ECG Case 081 • LITFL • ECG Top 100 Self-Assessment Quiz

A 74 yr old patient presents to the ER having suffered several episodes of chest pain over the preceding 24 hours. His past medical history includes hypertension, hyperlipidaemia, diabetes, and ischaemic cardiac disease.

A series of ECG’s are performed on this patient.

ECG 1: taken on arrival to the Emergency Department with the patient pain free.

ECG Case 081a LITFL Top 100 EKG — ECG 1 – Pain free on presentation

ECG 2: The patient then developed chest pain and the following ECG was recorded.

ECG Case 081b LITFL Top 100 EKG — ECG 2- Taken during an episode of chest pain

The episode of pain lasted only several minutes and resolved spontaneously.

ECG 3: taken 8 minutes after the second ECG with the patient now pain free.

ECG Case 081c LITFL Top 100 EKG — ECG 3 – Patient pain free, taken 8 minutes following ECG 2

Describe and interpret the ECGs

ECG ANSWER – ECG 1

This first ECG was taken on arrival to the Emergency Department with the patient pain free.

Rate:

Rhythm:

Regular
Sinus rhythm

Axis:

Borderline LAD (~ -30 deg)

Intervals:

PR – Normal (~180ms)
QRS – Normal (80ms)
QT – 400ms (QTc Bazett ~ 420 ms)

Segments:

Minor ST depression lead III

Additional:

T wave inversion leads II, III, aVF, V4, V5, V6
Biphasic T wave leads aVR, V3
Early precordial transition between V1 and V2
- Dominant R wave V2
Prominent T wave lead V2

ECG ANSWER – ECG 2

The patient then developed chest pain and the following ECG was recorded.

Rate:

Rhythm:

Regular
Sinus rhythm

Axis:

Normal (~20 deg)

Intervals:

PR – Normal (~200ms)
QRS – Normal (80ms)
QT – 360ms (QTc Bazett ~ 415 ms)

Segments:

ST Elevation leads II (2mm), III (3mm), aVF (2mm), V4 (1.5mm), V5 (1mm), V6 (1mm)
ST Depression aVR, aVL, V1, V2
- Note horizontal ST morphology in V2

Additional:

Pseudonormalisation of T waves leads II, III, aVF, V4, V5, V6
Early precordial transition between V1 and V2
- Dominant R wave V2
Prominent T wave lead V2

ECG ANSWER – ECG 3

The episode of pain lasted only several minutes and resolved spontaneously. This ECG was taken 8 minutes after the second ECG with the patient now pain free.

Rate:

Rhythm:

Regular
Sinus rhythm

Axis:

Borderline LAD (~ -30 deg)

Intervals:

PR – Normal (~180ms)
QRS – Normal (80ms)
QT – 380ms (QTc Bazett ~ 410 ms)

Segments:

ST elevation leads III, aVF
- Reduced compered with ECG 2

Additional:

T wave inversion leads II, III, aVF, V4, V5, V6
Early precordial transition between V1 and V2
- Dominant R wave V2
Prominent T wave lead V2

INTERPRETATION

ECG series showing ischaemia with re-perfusion (ECG 1), subsequent re-occlusion (ECG 2) with infero-postero-lateral STEMI, and spontaneous re-perfusion (ECG 3).

OUTCOME

The patient was immediately discussed with cardiology services. Treated with aspirin, clopidogrel, and placed on a heparin infusion and admitted to CCU. The patient remained pain free, troponin peaked at 12 hours, 4.8 (normal <0.05), and the patient was transfer the next day for angiography.

The angio showed: