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
















Rate:  

• 102

Rhythm:  

• Sinus

Axis:  

• LAD (-30 to -60)

Intervals:  

• PR – Prolonged (200 - 240ms)
• QRS - Normal (80ms) 
• QT - 440ms (QTc Bazette 310ms)

Segments:  

• ST Elevation aVR (3-4 mm) V1 (3mm) V2 (2mm) 
• ST Depression I, II, aVF, aVL, V4-6

Additional:  

• Notched p wave in lead II, possible biphasic P wave in V1
• Poor r wave progression

Interpretation:

• 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

Management

• 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

Interpretation:

• 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

• ST Elevation in aVR here & here

Textbook

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

Articles

• 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