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

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.

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

Rate:

60 bpm

Rhythm:

Regular
Sinus rhythm

Axis:

Normal

Intervals:

PR – Normal
QRS – Normal

Additional:

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

Interpretation:

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)

CLINICAL OUTCOME

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: