Friday, 10 October 2014

ECG of the Week - 6th October 2014 - Interpretation

These ECG's are from a 55 yr old female who presented with an hour of chest pain. She was a smoker and on treatment for hypercholesterolaemia.
Check out the comments on our original post here.






ECG 1
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ECG 2
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ECG 3
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ECG 4
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I'm going to tackle the interpretation of all the ECG's in one go to save duplicating the non-essential points.

Rate:
  • 72
Rhythm:
  • Sinus rhythm
    • ECG 1 shows a sinus arrhythmia
    • ECG's 2 show regular sinus rhythm

Axis:
  • Normal
Intervals:
  • PR - Normal (~160ms)
  • QRS - Normal (80-100ms)
  • QT - 320-360ms
Segments:

  • The is progressive ST segment changes during the 4 serial ECG recordings.
    • In ECG 1 ST elevation occurs in leads aVR(1mm), V1-2(1mm), V3(3-4mm) and V4 (1mm). 
    • During the serial ECG's we see the ST elevation in leads V1-4 progress, maximal on ECG 4 with ST elevation in V1(2mm), V2(1-2mm), V3(4-5mm) and V4 (3mm).
    • ECG 3 also shows early ST elevation in the inferior leads although this is less pronounced on ECG 4.
  • ST Depression leads I, V5-6
    • As the ECG's progress the ST depression resolves in leads V5-6 (potentially prior to becoming ST elevation)

Additional:

  • Hyperacute T-waves in leads II, III, aVF, V3-6
  • T-wave in V2 progressively becomes more hyper-acute as the ECG's progress
  • Biphasic T wave V1

Interpretation:

  • Progressing antero-septal ST elevation with hyperacute T-waves
  • Likely LAD lesion, I agree with Ken that I suspected a 'wrap-around' component due to the inferior changes best seen in the 3rd ECG


What happened ?

The patient was sent for urgent coronary angiogram which showed:

  • 100% LAD occlusion --> Stented
  • 30% mid-RCA stenosis

I don't have the full angio report so can't comment on the exact location of the lesion or the anatomy of the LAD.
The patient's echo post procedure showed dital anteroseptal and anteroapical akinesis with preserved systolic function.


References / Further Reading

KG-EKG Press


Life in the Fast Lane
Dr Venkatsen's Blog



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