Wednesday, 15 February 2012

ECG of Week - 13th Feb 2012 - Interpretation

We had two ECGs this week from the same patient.

ECG 1 - with chest pain

Click to enlarge

  • 102
  • Sinus
  • LAD (-30 to -60)
  • PR – Prolonged (200 - 240ms)
  • QRS - Normal (80ms) 
  • QT - 440ms (QTc Bazette 310ms)
  • ST Elevation aVR (3-4 mm) V1 (3mm) V2 (2mm) 
  • ST Depression I, II, aVF, aVL, V4-6
  • Notched p wave in lead II, possible biphasic P wave in V1
  • Poor r wave progression

  • Most marked abnormality is ST elevation in aVR, V1-2, with ST Depression I, II, aVF, aVL, V4-6
  • Also 1st Degree AV block and possible left atrialenlargement (p mitrale)

  • This pattern is most consistent with a LMCA occlusion (STE aVR >/= V1) 
  • LMCA occlusion associated with a high mortality (aVR STE>1.5mm up to 70% mortality)
  • Could also be proximal LAD lesion or severe 3-vessel disease

  • Urgent liaison with cardiology is required
  • Need to discuss reperfusion therapy based on available resources / local policies
  • Consideration of likelihood of requiring CABG is needed as this may affect initial drug therapy, particularly clopidogrel or prasugrel due to increased incidence of post operative bleeding

ECG 2 - Pain free post transfer

Click to enlarge

Key features:
  • ST Elevation V1-2 (1mm)
  • ST Depression I, aVL, V5-6

  • ST Elevation & Depression Resolving when compared with ECG 1

What happened next ?
  • Patient was reviewed and admitted by cardiology team
  • Planned for urgent angiography
  • Pt declined intervention
  • Re-presented with APO and cardiogenic shock

References / Further Reading

Life in the Fast Lane
  • ST Elevation in aVR here
  • More case reviews of STE in aVR here & here
  • Left Atrial Enlargement here 
Dr Smith's ECG Blog
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
  • Yamaji H, Iwasaki K, Kusachi S, Murakami T, Hirami R, Hamamoto H, Hina K, Kita T, Sakakibara N, Tsuji T. Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. ST segment elevation in lead aVR with less ST segment elevation in lead V(1). J Am Coll Cardiol. 2001 Nov 1;38(5):1348-54. PMID: 11691506 Full text
  • Kosuge M, Ebina T, Hibi K, Morita S, Endo M, Maejima N, et al. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol. 2011 Feb 15;107(4):495-500 PMID: 21184992


  1. Great ECG and interpretation.
    Some of the R waves in AVL go close to Sokolow-Lyon criteria for LVH (11mm) but they vary in height from beat to beat. LVH would also go with LAE and LAD. Though most MCA stenosis ECGs I've seen seem to have LAD.

    Did the patient get an Echo too?


  2. Hi Chris,

    We looked at the aVL complexes but as you say there is beat to beat variability, which makes it hard to call.
    I lost track of the patient following their representation so I don't have any echo results for them.