ECG Case 085

56 yr old male who present with 2 hours of chest pain. Past history of hypertension and smoking. The ECG’s were performed 15 mins apart with ongoing chest pain.

ECG 1; On arrival to ED

ECG Case 085a LITFL Top 100 EKG
ECG 1; On arrival to ED

ECG 2; 15 mins following ECG 1

ECG Case 085b LITFL Top 100 EKG
ECG 2; 15 mins following ECG 1

Describe and interpret this ECG

ECG ANSWER – ECG 1

Rate:

  • 72 bpm

Rhythm:

  • Sinus rhythm
  • Single PAC (Complex #7)

Axis:

  • Normal 

Intervals:

  • PR – Normal (160ms)
  • QRS – Normal (100ms)
  • QT – 360ms

Segments:

  • ST Depression leads I, V4-6

Interpretation:

  • Lateral ST segment depression
    • Given associated Hx of chest pain ischaemia is the main concern

ECG ANSWER – ECG 2

Rate:

  • 72 bpm

Rhythm:

  • Regular
  • Sinus rhythm

Axis:

  • Normal 

Intervals:

  • PR – Normal (180-200ms)
  • QRS – Normal (80ms)
  • QT – 360ms

Segments:

  • ST Depression leads I, II, aVL, V2-6
  • ST Elevation lead aVR (~1mm)

Additional:

  • Markedly prominent T waves leads I, V2-6

Interpretation:

  • De Winter T Wave Pattern
    • Suggests acute LAD lesion requiring emergent reperfusion 
  • Dynamic ECG changes compared with previous ECG

OUTCOME

The ECG changes were recognised by the treating team. The patient was taken for emergency PCI which showed:

  • LAD – 100% Occlusion – 2 x stents inserted
  • RAC – 30% proximal stenosis

Post stent echocardiogram showed:

  • Mild systolic dysfunction
  • Akinesis of anterior septum and apical region
  • LVEF ~40-45%

The patient was discharged after a 4 day in-patient stay.

I think there are two key learning points from this case:

  1. The need for serial ECG’s
  2. Recognition of De Winter’s T Wave Pattern

FURTHER READING

TOP 150 ECG SERIES



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

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