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

• Left axis deviation
• Right bundle branch block
• Inferior STEMI
• Old AMI

Textbook

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