ECG Case 081

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:

  • 66

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:

  • 84

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:

  • 66

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:

  • Right coronary: 98% stenosis –> stented
  • Circumflex: 80% stenosis
  • Left anterior descending: 80% proximal stenosis
  • Left main: 20% proximal stenosis
  • Left ventricle: Inferior hypokinesis with normal LV function

Check out the references belwo for some more great examples of re-perfusion / re-occlusion ECGs.



TOP 150 ECG SERIES



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

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