Wednesday, 5 July 2017

ECG of the Week - 3rd July 2017 - Interpretation

The following serial ECG's are from a 69 yr old female who presented with a history of intermittent chest pain. She was pain free on arrival to the Emergency Department and had a brief episode of self-resolving chest pain whilst in the Emergency Department.


  
ECG on presentation
Pain free
Click to enlarge
Key features
  • Regular sinus rhythm rate ~60-65 bpm
  • Normal axis
  • Biphasic T wave leads V2-4
    • Positive to negative deflection
  • T wave inversion lead aVL
  • Flat T wave lead I
  • Subtle ST aVR <1mm li="">


ECG during episode of chest pain
Click to enlarge 
Key features
  • Regular sinus rhythm rate 96 bpm
  • ST Elevation leads aVR (1mm) and V1 (1mm)
  • ST Depression leads I, II, III, aVF, V3-6
  • Note T inversion on pain-free ECG now positive deflection only

ECG 10 mins after ECG above
Pain free
Key features
  • Similar morphology to initial ECG
  • Regular sinus rhythm rate 78 bpm
  • Normal axis
  • Biphasic T wave leads V2-3
    • Positive to negative deflection
  • T wave inversion lead aVL
  • Flat T wave lead I
  • Subtle ST aVR more prominent than initial ECG
Impression
  • Serial ECG's showing dynamic ST and T wave changes
  • Pain-free ECG's showing Wellen's pattern
  • During episode of chest pain
    • Pseudo-normalisation of T wave change
    • Associated diffuse ST depression and ST elevation in aVR and V1
What happened ?

The patient was treated with dual anti-platelet therapy, heparinised and admitted under cardiology. She had a troponin (cTnI) of 0.22 ug/L and remained pain-free. Her angiogram showed:
  • LMCA: Irregularities
  • LAD: Proximal / Mid 70-80% culprit stenosis --> Stented
  • Cx: Irregularities
  • RCA: Irregularities
 Subsequent echo was essentially normal without wall motion abnormality or decreased ejection fraction.
 
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.