These ECGs are from a 58yr old male seen in a rural setting, approximately ~2500 km from the nearest tertiary centre.
He c/o intermittent atypical chest pain for several weeks without any cardiac risk factors.
At the clinic serial ECGs were performed and are below.
- What do you think of the ECGs ?
- What advice would you give assuming you were the clinician at the tertiary receiving hospital who was contacted regarding this case ?
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| First ECG Click to enlarge |
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| Second ECG Click to enlarge |
Challenge your assumptions.
ReplyDeleteAxis changes too much between the two for me not to consider a technical cause of the change.
Once ruled out, you can consider an evolving lateral wall MI as the cause of the ST/T-wave changes in the inferior leads.
I'd be willing to bet that the first (top) ECG was performed with all of the electrodes on the torso in a Modified Mason-Likar placement. The bottom ECG was probably performed with standard placement (i.e., arm and leg electrodes actually on the extremities).
ReplyDeleteJason,
ReplyDeleteI've not seen a 180 degree change in the axis before with Mason-Likar vs Limb Leads, usually no more than 15-30 degrees.
Have you seen that before without a lead swap of sorts?
Hi guys,
ReplyDeleteAs always thank you for your comments, I hope you enjoy the blog.
This is an interesting series of ECGs. Can I suggest looking specifically at leads aVL & aVF between the two ECGs and consider the net effect on leads I, II, III.
Thanks,
John Larkin
John,
ReplyDeleteThat was what I was alluding to with my "technical change" comment, as I believe the difference in the two ECG's to be attributable to electrode misplacement (LA-LL swap) rather than a primary change due to ACS.
LA<->LL: I->II, II->I, III->-III, aVR, aVL->aVF, aVF->aVL.
Thank you for the great cases!