Wednesday, 24 October 2018

ECG of the Week - 22nd October 2018 - Interpretation

This ECG is from a 65 yr old male who presented to a remote medical center, ~200 km from the nearest metropolitan hospital, complaining of chest pain.




Click to enlarge

Rate:
  • 78 bpm
Rhythm:
  • Regular
  • SInus Rhythm
Axis:
  • LAD
Intervals:
  • PR - Prolonged (~205ms)
  • QRS - Normal (90ms)
  • QT - 380ms (QTc Bazette 430 ms)
Additional:

  • ST Elevation leads V2-5
  • ST Depression lead aVR
  • Prominent T wave lead II

Interpretation:

  • Anterior STEMI

Given the remote location this patient was thrombolysed and subsequently transferred for further tertiary management. I don't have the results of his subsequent angiogram or echo unfortunately.

What are the contraindications to thrombolysis ?

If you work in a metropolitan or tertiary center you probably send all your STEMI's for urgent angiography but it remote and rural centers thrombolysis must be considered.
The following list is taken from the Australian Resuscitation Council Guideline 14.3 'Acute Coronary Syndromes: Reperfusion Strategy'.

Contraindications to thrombolysis in STEMI
ARC Guideline 14.3
Click to enlarge

What agents can you use and how are they given ?
  • Streptokinase 1.5 million units iv over 60 minutes
  • Alteplase initial iv bolus plus variable dose infusion over 90 minutes
  • Reteplase 10 units iv over 2 minutes followed 30 minutes later by a further 10 units iv over 2 minutes
  • Tenecteplase 30-50mg iv bolus depending on patient's weight

What are the complications of thrombolysis for STEMI ?

  • Haemorrhage ~10%
  • Intracranial haemorrhage ~0.8%
  • Allergic reaction / anaphylaxis
  • Hypotension
  • Myocardial rupture if thrombolysis given greater than 12 hrs onset ischaemia
  • Re-perfusion arrhythmias
  • Re-occlusion / Re-infarction
  • Bone pain with streptokinase
References / Further Reading

Life in the Fast Lane

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

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