Friday, 13 June 2014

ECG of the Week - 9th June 2014 - Interpretation

This week's ECG is from a 50 year old male who presents with several days of intermittent chest pain. Nil significant past medical history. This ECG was performed whilst the patient had chest pain.
Check out the comments on our original post here.



Click to enlarge

Rate:
  • 72 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (120ms)
  • QRS - Normal (80-100ms)
  • QT - 360ms (QTc Bazette 380-400 ms)
Segments:

  • ST Elevation leads V1 (0.5mm), V2 (1.5mm), V3 (1mm), V4 (0.5mm), aVL (subtle - thanks Ken)
  • ST Depression leads II, III, aVF

Additional:

  • Biphasic (up-down) T waves leads V2, V3
  • T wave inversion leads I, V4-6
  • Q waves leads I, II, III, aVF, V2-6

What happened ?

No old ECG's available. ECG performed by GP ~1 hour earlier showed identical changes to above ECG, serial ECGs within the ECG showed no dynamic change, and interestingly the ECG post intervention remained the same as above.
Urgent cardiology review was arranged given ECG features and on-going pain.
The patient was given aspirin, ticagrelor, heparin, opiates, GTN and was taken for urgent angiography which showed:
  • LMCA - normal
  • Prox LAD - irregularities
  • Mid LAD - 90% lesion TIMI II distal flow --> PCI
  • Cx - irregularities
  • RCA - irregularities

Pre-PCA to LAD
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Post-PCA to LAD
Click to enlarge

Post angio ECHO showed:
  • Regional wall motion abnormalities infero-antero-septal regions
  • EF 50% 
  • Normal valvular function
Troponin peaked at 11 (normal <0.05) and the patient was discharge after an uneventful in-patient recovery.

Interpretation:

I think this one is tricky and as you can see above was associated with a mid-LAD lesion. 
Given the precordial Q waves, on-going chest pain, and high biomarker rise we can't say this is a true Wellen's pattern, although at a brief glance the T wave changes are the most striking ECG feature. Given the 3 days of preceding pain I wonder how 'acute' this ECG is, especially given the non-dynamic changes. Dr Steve Smith has very kindly agreed to share his opinion on this case with me and I will update the post with his thoughts over the weekend.

References / Further Reading

Life in the Fast Lane

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