ECG Case 100

31 yr old female who is 5 days post-partum she was brought to the Emergency Department following a episode of collapse. On arrival to the Emergency Department she was hypotensive (systolic BP ~80 mmHg) with an altered conscious level, complaining of chest pain and headache.

ECG Case 100a LITFL Top 100 EKG

Describe and interpret this ECG



  • 60 bpm


  • Regular
  • Sinus rhythm


  • Normal


  • PR – Normal
  • QRS – Normal


  • ST Elevation in leads aVR & aVL (<1mm font=””>
  • Upsloping ST depression in leads V2-6 
    • Maximal in leads V3-4
  • Flat ST depression in the inferior leads
  • Prominent T waves in leads V2-4 


  • Features consistent with a De Winter pattern
    • Suggesting potential LAD pathology
    • DDx Demand ischaemia / perfusion mismatch

Given the patients age and medical history broader differentials for shock and ischaemic ECG features would be:

  • PE
  • Sepsis
  • Endocrine – Sheehan Syndrome (postpartum pituitary gland necrosis)


Following review of the initial ECG urgent cardiology input was obtained and an emergent CTPA was performed to exclude PE as a potential cause.

On return from a negative CTPA the patient complained of further chest pain, repeat ECG below:

Clear anterolateral ST elevation and inferior ST depression. The patient was transferred for urgent angiography which showed a 90% mid LAD lesion treated with bioresorbable stent.

Subsequent CTPA revealed a coronary artery dissection as the cause for the acute LAD lesion.

Spontaneous Coronary Artery Dissection (SCAD)

This is a rare phenomena occurring in ~4% of all acute MI’s. Approximately 90% of cases occur in females and it accounts for 1/4 of MI’s in the under 50 yr old age group. Recurrence rate is between 13-18%.
There are multiple risk factors including:

  • Fibromuscular dysplasia
  • Pregnancy
  • Connective tissue disorders
  • Systemic inflammatory conditions
  • Intense exercise
  • Intense emotional stress
  • Labour and delivery
  • Valsalva-like events
  • Sympathomimetic use

TOP 150 ECG Series

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

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