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

• Wellen's

Textbook

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