Wednesday, 12 April 2017

ECG of the Week - 10th April - Interpretation

These ECG's are from a 75yr old with a history of prior STEMI, T2DM and cardiomyopathy (EF 25%). He presented with acute chest pain, nausea and diaphoresis.




ECG on acute presentation
Click to enlarge
Key features:

  • Sinus rhythm, rate ~66 bpm
  • Left axis deviation
  • RBBB
    • Increased QRS widening compared with old ECG below
    • Completion of RBBB compared with old ECG
  • ST Elevation
    • Lead III 1mm 
    • Lead aVF ~1mm
    • Lead II - up-sloping ST
    • All new compared with old ECG
  • ST Depression
    • Leads V1-3, aVL
    • All new compared with old ECG
  • Hyperacute T waves inferolateral leads
    • All new compared with old ECG
  • Deep Q wave leads III, aVF
    • Old changes but higher voltage ? positional vs interval change




ECG from 2 years prior
Click to enlarge
Key features:

  • Sinus rhythm, rate ~78 bpm
  • Left axis deviation
  • Narrow QRS
  • High right precordial voltages
  • Deep Q waves in leads III, aVF
  • Single PVC

Interpretation:

  • Acute inferior STEMI on a background of prior inferior AMI
Note the acute differences in ST segment and T wave morphology between the acute presentation ECG and an old ECG.

What happened ?

The patient was taken for urgent angiography which showed:

  • LMCA: Minor irregularities
  • LAD: Long segment diffuse disease
  • Cx: Patent stent, distal 70% stenosis
  • RCA: Dominant vessel. Proximal occlusion of PLV branch --> stented
The patient made an uneventful recovery and was discharge with out-patient cardiology follow-up.

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.