ECG of the Week: ECG of the Week - 8th January 2018

Wednesday 10 January 2018

ECG of the Week - 8th January 2018 - Interpretation

The following ECG is from a 31 yr old female who is 5 days post-partum she was brought to the Emergency Department following a episode of collapse. On arrival to the Emergency Department she was hypotensive ( Systolic BP ~80 mmHg) with an altered conscious level complaining of chest pain and headache.

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Rate:

60 bpm

Rhythm:

Regular
Sinus rhythm

Axis:

Normal

Intervals:

PR - Normal
QRS - Normal

Additional:

ST Elevation in leads aVR & aVL (<1mm font="">
Upsloping ST depression in leads V2-6

Maximal in leads V3-4

Flat ST depression in the inferior leads
Prominent T waves in leads V2-4

Interpretation:

Features consistent with a De Winter's pattern

Suggesting potential LAD pathology
DDx Demand ischaemia / perfusion mismatch

Given the patients age and medical history broader differentials for shock and ischaemic ECG features would be:

PE
Sepsis
Endocrine - Sheehan's Syndrome

What happened ?

The patient was initially treated with iv fluid, analgesia and broad spectrum iv antibiotics ( as initial broad DDx included sepsis). Following review of the initial ECG urgent cardiology input was obtained and an emergent CTPA was performed to exclude PE as a potential cause. On return from a negative CTPA the patient complained of further chest pain, repeat ECG below:

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Clear anterolateral ST elevation and inferior ST depression. The patient was transferred for urgent angiography which showed a 90% mid LAD lesion treated with bioresorbable stent. Subsequent CTPA revealed a coronary artery dissection as the cause for the acute LAD lesion.

Coronary Artery Dissection
This is a rare phenomena occurring in ~4% of all acute MI's. Approximately 90% of cases occur in females and it accounts for 1/4 of MI's in the under 50 yr old age group. Recurrence rate is between 13-18%.
There are multiple risk factors including: