ECG of the Week - 21st March 2016 - Interpretation

The following ECG's are from a 58 yr old male who presented with chest pain onset 30 mins prior. He had an episode of exertional chest pain the day prior and is a smoker. The ECG's were performed 10 minutes apart.

Click to enlarge

Rate:

• 54 bpm

Rhythm:

• Regular
• Sinus rhythm

Axis:

• Normal

Intervals:

• PR - Normal (~180ms)
• QRS - Normal (100ms)
• QT - 440ms

Segments:

• ST Elevation leads aVR, V1 (1-1.5mm), V2 (<1mm)
• ST Depression leads I, II, V4-6

Additional:

• Marked hyperacute T waves in leads V2-4
• Some ST segment analysis is difficult due to baseline artifact
• T wave inversion lead III

Interpretation:

• De Winter's Pattern
• Hyperacute T waves with associated ST depression in leads V2-6
• Possible ST elevation aVR
• See the following ECG library review from LitFL for more information on De Winter's hyperacute T waves

Click to enlarge

Rate:

• 72 bpm

Rhythm:

• Regular
• Sinus Rhythm

Axis:

• Normal

Intervals:

• PR - Normal (~160ms)
• QRS - Normal (80ms)
• QT - 400ms

Segments:

• ST Elevation leads aVR, V1-4, aVL
• ST Depression III, aVF, V5-6

Interpretation:

• Progressive ST segment change from the 1st ECG with clear STEMI pattern

What happened ?

The patient went for urgent angiography which showed:

• LM: Normal
• LAD: Proximal 80% Mid 70% stenosis
• LCx: moderate diffuse disease
• RCA (Dominant): Mild 50%, Distal 70% PLV 80%
• LV: Anterior hypokinesia with mild-mod LV dysfunction

The LAD lesion under DES PCI and the patient returned to hospital 2 months later for an elective staged PCI to the RCA.

References / Further Reading

Life in the Fast Lane

• Anterior STEMI
• De Winter's T waves

Textbook

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