ECG Guru - Instructor Resources - STEMI https://www.ecgguru.com/ecg/stemi en Acute Anterior-lateral STEMI https://www.ecgguru.com/ecg/acute-anterior-lateral-stemi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/acute-anterior-lateral-stemi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/030123%20Ant-Lat%20MI%201%20Edit.jpg" width="1800" height="781" alt="" /></a></div><div class="field-item odd"><a href="/ecg/acute-anterior-lateral-stemi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/030123%20Ant-Lat%20MI%202%20%20Edit.jpg" width="1800" height="782" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp; </span>A 60-year-old man at work. He experienced a sudden onset of substernal chest pain, nausea &amp; vomiting, and dizziness.<span style="mso-spacerun: yes;">&nbsp; </span>He states the pain is a 5 on 1-10 scale.<span style="mso-spacerun: yes;">&nbsp; </span>No cardiac history or current medications.</span><strong><span style="font-size: 8.0pt; line-height: 107%; color: #00b050;">&nbsp;</span></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The ECGs:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">The first ECG</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">, taken at 12:30:05, shows a sinus rhythm with ventricular bigeminy. In some leads, you can see the sinus P waves hidden in the beginnings of the PVCs, so we know the underlying sinus rhythm is about 82 bpm.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">There is obvious <strong>ST elevation</strong> in V1 through V5, which is the anterior wall, an area perfused by the left anterior descending artery.<span style="mso-spacerun: yes;">&nbsp; </span>Remember – the ST elevation sign may also show in the PVCs, but because ventricular beats have secondary ST changes of their own, we should assess <strong>only the sinus beats</strong> for ST changes.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">There is also obvious ST elevation in Leads I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>This is the high lateral wall, which is perfused by the circumflex and first diagonal arteries, both proximal branches of the left coronary artery.<span style="mso-spacerun: yes;">&nbsp; </span>So, the involvement of the high lateral wall indicates a proximal lesion in the LCA – not good.<span style="mso-spacerun: yes;">&nbsp; </span>Leads III and aVF have distinct ST depression – this is a reciprocal change reflecting the ST elevation in Leads I and aVL. </span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">The second ECG</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">, taken 42 seconds later, gives us a look at the same ECG without the PVCs.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">Even though this is an “obvious” ST elevation M.I., it is good to note other signs of M.I. on this tracing, for times when the STE is not so obvious.<span style="mso-spacerun: yes;">&nbsp; </span>The reciprocal ST depression may, in some cases, show up before the STE.<span style="mso-spacerun: yes;">&nbsp; </span>An even earlier sign of impending occlusive M.I. is the appearance of <strong>hyperacute T waves</strong>, which can precede the STE.<span style="mso-spacerun: yes;">&nbsp; </span>V2 through V5 show the tall, broad hyperacute T waves that are still present, after the onset of STE.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">Note:<span style="mso-spacerun: yes;">&nbsp; </span>V4 has a “fishhook” appearance at the J point.<span style="mso-spacerun: yes;">&nbsp; </span>This is often associated with early repolarization pattern, but that is not what this is.<span style="mso-spacerun: yes;">&nbsp; </span>So-called “benign early repolarization” occurs in younger people, and does not cause the other signs of acute STEMI that we see on this ECG.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">Follow Up:</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;"><span style="mso-spacerun: yes;">&nbsp; </span>The patient suffered a cardiac arrest shortly after arriving at the hospital.<span style="mso-spacerun: yes;">&nbsp; </span>Unfortunately, we do not know the outcome.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><em><span style="font-size: 10.0pt; line-height: 107%; color: black; mso-themecolor: text1;">Our thanks to Paramedic Ashley Terrana for donating these images.</span></em></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Acute Anterior-lateral STEMI 1/5</option><option value="40">Give Acute Anterior-lateral STEMI 2/5</option><option value="60">Give Acute Anterior-lateral STEMI 3/5</option><option value="80" selected="selected">Give Acute Anterior-lateral STEMI 4/5</option><option value="100">Give Acute Anterior-lateral STEMI 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >2</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-f61H91uMXYlITSA5Ap3XuwwDyWIxYslOLlNW4B0bF3A" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/awmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AWMI</a></div><div class="field-item even"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item odd"><a href="/ecg/anterior-lateral-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior-lateral M.I.</a></div><div class="field-item even"><a href="/ecg/acs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ACS</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div><div class="field-item odd"><a href="/ecg/hyperacute-t-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperacute T waves</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Facute-anterior-lateral-stemi&amp;title=Acute%20Anterior-lateral%20STEMI"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Sun, 24 Dec 2023 03:15:06 +0000 Dawn 892 at https://www.ecgguru.com https://www.ecgguru.com/ecg/acute-anterior-lateral-stemi#comments Isolated Posterior Wall M.I. https://www.ecgguru.com/ecg/isolated-posterior-wall-mi-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/isolated-posterior-wall-mi-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/110923%20PWMI%20isolated%20standard%2012-Lead.jpg" width="1800" height="1135" alt="" /></a></div><div class="field-item odd"><a href="/ecg/isolated-posterior-wall-mi-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/110923%20PWMI%20isolated%20Posterior%20Leads%20edit.jpg" width="1800" height="1355" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left">This interesting case was provided by Dr. Bojana Uzelac, Emergency Medicine physician. <span style="mso-spacerun: yes;">&nbsp;</span>We are paraphrasing a translation of her comments here.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The patient</span></strong> is a 50-year-old complaining of chest pain.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The ECG</span></strong> shows a rare occurrence – an isolated POSTERIOR WALL MI (PWMI).<span style="mso-spacerun: yes;">&nbsp; </span>Note that leads V1 through V4 show the usual signs of posterior wall MI.<span style="mso-spacerun: yes;">&nbsp; </span>We see ST segment depression, which represents a reciprocal view of the ST elevation present on the posterior wall of the left ventricle.<span style="mso-spacerun: yes;">&nbsp; </span>The relatively tall, wide R waves in V2 and possibly V3 represent pathological Q waves on the posterior wall. (V2 R/S ratio &gt; 1). What is unusual here is that there are no signs of inferior wall MI or lateral wall MI.<span style="mso-spacerun: yes;">&nbsp; </span>Posterior wall MI usually occurs in conjunction with one of these.</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span>PWMI is most often seen as an extension of <strong>inferior wall MI or lateral wall MI,</strong> because of shared blood supply.&nbsp; Usually, it is the right coronary artery that supplies both the posterior and inferior areas of the left ventricle (about 80% - 85% of the population).&nbsp; In some individuals, the circumflex artery supplies both areas. Posterior M.I. may also be seen in conjunction with <strong>lateral wall MI</strong>, when the circumflex supplies the posterior and lateral walls.&nbsp; In the case shown here, <strong>only</strong> the posterior wall is involved.&nbsp; Most cases of isolated PWMI involve either the circumflex or one of its marginal (OM) branches.&nbsp; Only about 3.3% - 5% of all MIs are isolated PWMI.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span>The second ECG shown here has Leads V7, V8, and V9 replacing V4 – V6.&nbsp; These posterior leads confirm the posterior M.I. with ST elevation.&nbsp; Posterior M.I. can be confirmed with STE of &gt; .5 mm in two of the three leads.&nbsp; The sensitivity for this finding is not known, but specificity is almost 100%.&nbsp; Performance of posterior leads has been shown clinically to improve chances of recognizing IPWMI. It is generally considered to be a good idea to perform posterior leads on patients with symptoms of M.I., but no ST elevation on the standard 12-Lead ECG. For electrode placement, see <a href="https://www.ecgguru.com/heart-illustrations/illustration-posterior-leads">HERE</a>.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span><strong><span style="color: #00b050;">Followup&nbsp; </span></strong>The patient was taken to the cath lab, where the circumflex artery was found to be 100% occluded.&nbsp; The patient’s outcome was good.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span><strong><span style="color: #00b050;">Some additional resources:</span></strong><span style="color: #00b050;">&nbsp; </span>NIH, National Library of Medicine, Posterior myocardial infarction.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left"><a href="https://www.ncbi.nlm.nih.gov/books/NBK553168/">https://www.ncbi.nlm.nih.gov/books/NBK553168/</a></p><p class="MsoNormal" style="text-align: left;" align="left">NIH, National Library of Medicine, Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-Lead electrocardiography: a case series.<span style="mso-spacerun: yes;">&nbsp; </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9420295/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9420295/</a></p><p class="MsoNormal" style="text-align: left;" align="left">Thank to Dr. Bojana Uzelac of Serbia for sharing this important example with us.&nbsp; To follow her on Facebook, follow this link: <a href="https://www.facebook.com/profile.php?id=100090459765248&amp;mibextid=ZbWKwL">https://www.facebook.com/profile.php?id=100090459765248&amp;mibextid=ZbWKwL</a></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--2" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--4" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Isolated Posterior Wall M.I. 1/5</option><option value="40">Give Isolated Posterior Wall M.I. 2/5</option><option value="60">Give Isolated Posterior Wall M.I. 3/5</option><option value="80" selected="selected">Give Isolated Posterior Wall M.I. 4/5</option><option value="100">Give Isolated Posterior Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form--vkVu9HyxF6gxDVbMV9eEWN3zPAtlXX9VX01neT6fOw" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/isolated-posterior-wall-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Isolated posterior wall MI</a></div><div class="field-item odd"><a href="/ecg/ipwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IPWMI</a></div><div class="field-item even"><a href="/ecg/posterior-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Posterior MI</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/circumflex-artery-occlustion" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Circumflex artery occlustion</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fisolated-posterior-wall-mi-0&amp;title=Isolated%20Posterior%20Wall%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 11 Nov 2023 21:51:23 +0000 Dawn 877 at https://www.ecgguru.com https://www.ecgguru.com/ecg/isolated-posterior-wall-mi-0#comments Inferior Posterior Wall M.I. In Cabrera Format https://www.ecgguru.com/ecg/inferior-posterior-wall-mi-cabrera-format <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-posterior-wall-mi-cabrera-format"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/112022%20IWMI%20Cabrera%20%20Format%20%233%20%20Edit%20for%20Guru.jpg" width="2400" height="438" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left">Does something about this ECG look "different" to you?&nbsp; &nbsp; This ECG shows a “classic” presentation of inferior-posterior M.I. when it is caused by a lesion in the <strong>right coronary artery (RCA).</strong> There are ST elevations in leads II, III, and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>Reciprocal ST depression is seen in Leads I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>There is also reciprocal ST depression in Leads V1 – V3.<span style="mso-spacerun: yes;">&nbsp; </span>These more rightward anterior leads are reciprocal to the posterior (or posterior-lateral) wall, so the ST <em>elevation</em> is actually posterior.<span style="mso-spacerun: yes;">&nbsp; </span>Another sign that this is an RCA lesion is that the ST elevation in Lead III looks <em>worse</em> than the STE in Lead II.<span style="mso-spacerun: yes;">&nbsp; </span>It would be helpful to check the right precordial leads, or at least V4 Right, as elevation there would indicate right ventricular M.I.&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left">Depending on how experienced you are at evaluating ECGs, you might have immediately noticed something “different” about this tracing.<span style="mso-spacerun: yes;">&nbsp; </span>It is printed in Cabrera format, which groups the leads (viewpoints) more geographically than a traditional ECG does.<span style="mso-spacerun: yes;">&nbsp; In addition to grouping the leads more geographically, instead of aVR, the machine records - aVR.&nbsp; That reverses the negative and positive poles of aVR, putting the positive ("seeking") electrode at 30 degrees - halfway between Leads I and II.&nbsp;&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span>Those of us who have been looking at ECGs for decades often feel a bit disconcerted by this format, because we have developed almost an intuitive way of seeing the ECG as a “map”, and this rearrangement thwarts our brains’ approach to the ECG.<span style="mso-spacerun: yes;">&nbsp; </span>I would imagine, however, that this might make interpretation a bit easier for someone who is not prejudiced by the standard way of printing.<span style="mso-spacerun: yes;">&nbsp; </span>This method is especially helpful when looking for inferior wall M.I., as we see here, because the lateral leads are together in a row, and the inferior leads are grouped together.&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left">ECGs are “standardized” all over the world.<span style="mso-spacerun: yes;">&nbsp; </span>This makes them easier for most of us to develop our interpretation skills.<span style="mso-spacerun: yes;">&nbsp; </span>But, there are still options available to individuals, and some are popular in certain countries.<span style="mso-spacerun: yes;">&nbsp; </span>Watch for Cabrera format, as well as changes in paper speed (50 mm/min or 12.5 mm/min instead of 25 mm/min).<span style="mso-spacerun: yes;">&nbsp; </span>You might run across ECGs that have had the voltage measurements enhanced. You can determine this by looking at the standardization markers, which will be exactly 2 big boxes tall if set to the most common standard of 10 mm (10 small boxes) being equal to 1 mV.</p><p class="MsoNormal" style="text-align: left;" align="left"><img src="/sites/default/files/small_Standard%20Marker%2C%20Labelled.jpg" width="90" height="90" /></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--3" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--6" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Posterior Wall M.I. In Cabrera Format 1/5</option><option value="40">Give Inferior Posterior Wall M.I. In Cabrera Format 2/5</option><option value="60">Give Inferior Posterior Wall M.I. In Cabrera Format 3/5</option><option value="80" selected="selected">Give Inferior Posterior Wall M.I. In Cabrera Format 4/5</option><option value="100">Give Inferior Posterior Wall M.I. In Cabrera Format 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-4M5ZfdXqdI5jFdDx5jzMikzb25Y7lkfwArpLs-k1LQo" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item odd"><a href="/ecg/inferior-posterior-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-posterior M.I.</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/cabrera-format" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Cabrera format</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-posterior-wall-mi-cabrera-format&amp;title=Inferior%20Posterior%20Wall%20M.I.%20In%20Cabrera%20Format"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 26 Aug 2023 22:53:09 +0000 Dawn 866 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-posterior-wall-mi-cabrera-format#comments Severe Triple Vessel Disease https://www.ecgguru.com/ecg/severe-triple-vessel-disease <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/severe-triple-vessel-disease"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/072923%20Triple%20Vessel%20Disease%20Ed.jpg" width="1800" height="1117" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The Patient:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: black; mso-color-alt: windowtext;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>This ECG is from a 63-year-old man who complained of epigastric pain for three hours. The pain was sudden in onset, burning in nature, and accompanied by nausea and palpitations.<span style="mso-spacerun: yes;">&nbsp; </span></span><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">The patient is a heavy smoker, diabetic and hypertensive&nbsp;with a long history of non-compliance to his medications.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">He was given crushed aspirin, loaded with clopidogrel and heparin, given high-intensity statins, and rushed to the cath lab.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The ECG:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-spacerun: yes;">&nbsp; </span>The rhythm is normal sinus, a bit fast at 90 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The intervals, frontal plane axis, and R wave progression are normal.&nbsp;&nbsp;</span>This ECG shows a very dreaded pattern:&nbsp; ST segment elevation in aVR and V1 with widespread ST depression, seen here in all other leads.&nbsp; This is an ECG sign of GLOBAL ISCHEMIA.&nbsp; There are several possible causes, all bad.&nbsp; The most common causes of this pattern are:</p><p class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Severe triple vessel disease, with significantly decreased flow in the left anterior descending, right, and circumflex arteries.</span></p><p class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><span style="text-indent: -0.25in; font-family: Symbol;">·<span style="font-variant-numeric: normal; font-variant-east-asian: normal; font-variant-alternates: normal; font-kerning: auto; font-optical-sizing: auto; font-feature-settings: normal; font-variation-settings: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><span style="text-indent: -0.25in;">Significant narrowing and decreased blood flow in the left main coronary artery.</span></p><p class="MsoListParagraphCxSpLast" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Severe shock state, affecting perfusion in the entire body.</span><strong><span style="font-size: 8.0pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">&nbsp;</span></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The Outcome:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-spacerun: yes;">&nbsp; </span>The patient’s results in the cath lab include:</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="color: #222222;">LMCA: 80-85% occlusion</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">LAD: 90-95% occlusion&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">RCA: 75-80% occlusion&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">The first and second diagonal branches of the LAD: 60-65% occlusion</span><span style="color: #222222; font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">There was near global hypokinesia, probably due to stunning of the cardiac muscle.&nbsp;</span><span style="color: #222222; font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">His ejection fraction (EF): 25-30%&nbsp;(Normal is 60%).</span><span style="color: #222222; font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">A good lesson here is that not everyone experiences “crushing substernal chest pain, radiating to the left arm and jaw”.<span style="mso-spacerun: yes;">&nbsp; </span>The presentation and patient history are very important, and in this case very indicative of cardiac disease.</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">&nbsp;T</span><span style="color: #222222;">hank you to <strong>Dr. Mohammad Al-Shatnawi </strong>for providing this interesting case.</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--4" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--8" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Severe Triple Vessel Disease 1/5</option><option value="40">Give Severe Triple Vessel Disease 2/5</option><option value="60">Give Severe Triple Vessel Disease 3/5</option><option value="80" selected="selected">Give Severe Triple Vessel Disease 4/5</option><option value="100">Give Severe Triple Vessel Disease 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-tmGpnkBx18ybUSMu2oU56EbkWB4CL-iFW9yNZObaxjg" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/triple-vessel-disease" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Triple vessel disease</a></div><div class="field-item odd"><a href="/ecg/global-ischemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Global ischemia</a></div><div class="field-item even"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fsevere-triple-vessel-disease&amp;title=Severe%20Triple%20Vessel%20Disease"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 30 Jul 2023 23:01:07 +0000 Dawn 855 at https://www.ecgguru.com https://www.ecgguru.com/ecg/severe-triple-vessel-disease#comments Inferior Posterior M.I. https://www.ecgguru.com/ecg/inferior-posterior-mi-1 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-posterior-mi-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/111222%20IWMI%20Ed%20ON%20GURU.jpg" width="1291" height="620" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This is a "classic" ECG of very good quality for you to use in a classroom setting.</p><p><strong>The Patient:</strong>&nbsp; A 57-year-old man who complains of a sudden onset of "sharp" chest pain while on a long bike ride.&nbsp; The pain does not radiate, and nothing makes it worse or better.&nbsp; He is pale, cool, and diaphoretic.&nbsp; His medical history is unknown.</p><p><strong>The ECG:</strong>&nbsp; This ECG could be considered "classic" for an inferior wall ST elevation M.I. caused by occlusion of the right coronary artery.&nbsp; ECG findings include:</p><p>*&nbsp; &nbsp;Normal sinus rhythm</p><p>*&nbsp; &nbsp;Marked ST elevation in Leads II, III, and aVF.&nbsp; The elevation is higher in Lead III than in Lead II, a reliable sign of RCA occlusion.</p><p>*&nbsp; &nbsp;Reciprocal depression in Leads aVL and I.&nbsp; ST depression in the setting of acute transmural ischemia (STEMI) is almost ALWAYS due to&nbsp; reciprocal change. The fact that this STD is localized to leads that are reciprocal to the inferior wall is proof of the nature of the STD.</p><p>*&nbsp; &nbsp;Reciprocal depression in V1 - V3.&nbsp; More localized depression.&nbsp; What wall is reciprocal to the anterior-septal wall?&nbsp; The posterior (postero-lateral).&nbsp; Since the inferior wall is really the lower part of the posterior wall, inferior wall M.I. is often accompanied by posterior wall M.I.</p><p>An additional lead, V4R, is helpful in this situation, since the right ventricle is often affected in RCA occlusions.&nbsp; The EMS crew reports that V4R was negative for ST elevation, but we do not have a copy.</p><p>Small q waves have formed in Lead III, and we would watch for progression of this sign, as it can indicate necrosis.</p><p><strong>Outcome:</strong>&nbsp; The patient went to the cath lab, but we have no further followup.</p><p>&nbsp;</p><p>Our thanks to Ashley Terrana for donating this tracing.</p><p>&nbsp;</p><p>&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--5" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--10" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Posterior M.I. 1/5</option><option value="40">Give Inferior Posterior M.I. 2/5</option><option value="60">Give Inferior Posterior M.I. 3/5</option><option value="80" selected="selected">Give Inferior Posterior M.I. 4/5</option><option value="100">Give Inferior Posterior M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-LGtGQdQb8vEULzlDQ-o3P_M9_Nwy8foTdQa-gCH6k0Q" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div><div class="field-item odd"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/inferior-posterior-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-posterior M.I.</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_5"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-posterior-mi-1&amp;title=Inferior%20Posterior%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 24 Jul 2023 20:41:39 +0000 Dawn 850 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-posterior-mi-1#comments Acute Anterior M.I. and Ventricular Fibrillation https://www.ecgguru.com/ecg/acute-anterior-mi-and-ventricular-fibrillation <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/acute-anterior-mi-and-ventricular-fibrillation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/032923%20AWMI%20from%20Travis%20Britt%2015%20Lead%201446%20Ed.jpg" width="1800" height="645" alt="" /></a></div><div class="field-item odd"><a href="/ecg/acute-anterior-mi-and-ventricular-fibrillation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/032923%20AWMI%20from%20Travis%20Britt%2012%20Lead%201449%20Ed.jpg" width="1800" height="621" alt="" /></a></div><div class="field-item even"><a href="/ecg/acute-anterior-mi-and-ventricular-fibrillation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/032923%20AWMI%201451%20VF%20to%20shock%20ed_0.jpg" width="1800" height="845" alt="" /></a></div><div class="field-item odd"><a href="/ecg/acute-anterior-mi-and-ventricular-fibrillation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/032923%20Cath%20lab%20image%20100%20%25%20LAD%20small%20for%20Guru.jpg" width="597" height="642" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">The Patient:</span></strong><span style="font-size: 12.0pt;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>This series of ECGs is from a 65-year-old woman who was complaining of a sudden onset of chest pain, nausea, and weakness. She stated that the pain increased on inspiration.<span style="mso-spacerun: yes;">&nbsp; </span>She reported a history of non-insulin-dependent diabetes mellitus (NIDDM).</span><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">&nbsp;</span></strong></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">ECG No. 1, 14:46:</span></strong><span style="font-size: 12.0pt;"><span style="mso-spacerun: yes;">&nbsp; </span>This ECG includes V4Right, V8 and V9 in place of V4, V5, and V6.<span style="mso-spacerun: yes;">&nbsp; </span>The rhythm is sinus at 91 beats per minute.<span style="mso-spacerun: yes;">&nbsp; </span>The PR interval is within normal limits, as is the QRS duration.<span style="mso-spacerun: yes;">&nbsp; </span>The QTc is WNL as well.<span style="mso-spacerun: yes;">&nbsp; </span>The frontal plane axis is also WNL.<span style="mso-spacerun: yes;">&nbsp; </span>The three standard chest leads show an early transition of R waves in V2. <span style="mso-spacerun: yes;">&nbsp;&nbsp;</span>There are noticeable ST and T wave abnormalities:</span></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><span style="font-size: 12.0pt;">slight ST elevation in I and aVL with ST depression in II, III, and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>In chest pain, possible M.I., STD should be presumed to be reciprocal in nature.<span style="mso-spacerun: yes;">&nbsp; </span>V1 has slight STE with a coved upward (frowning) appearance.<span style="mso-spacerun: yes;">&nbsp; </span>V2 has more noticeable STE, with a tall, wide-based T wave. This is called a “hyperacute T wave”.<span style="mso-spacerun: yes;">&nbsp; </span>We will have to evaluate V4 – V6 on ECG No. 2.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><span style="font-size: 12.0pt;">V4 Right has no ST elevation, and V8 and V9 have ST depression (reciprocal to the anterior leads).<span style="mso-spacerun: yes;">&nbsp; </span>So far, we have all the signs of <strong>acute anterior wall M.I.</strong></span><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">&nbsp;</span></strong></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">ECG No. 2, 14:49:</span></strong><strong><span style="font-size: 12.0pt;"><span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 12.0pt;">This ECG, taken three minutes later, includes the 12 “standard” leads.<span style="mso-spacerun: yes;">&nbsp; </span>The ST depression in the inferior wall has increased slightly. There is not much change in the anterior STE.<span style="mso-spacerun: yes;">&nbsp; </span>There is movement artifact in the first half of the ECG.<span style="mso-spacerun: yes;">&nbsp; </span>Leads V5 and V6 show STD.&nbsp;</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">Rhythm Strip at 14:51:</span></strong><span style="font-size: 12.0pt;"> Shows v fib, and a 360 J defibrillation that resulted in sinus tach with wide QRS complexes.<span style="mso-spacerun: yes;">&nbsp; </span>The rhythm just before the v fib was more “organized” looking, with regular, fast QRS complexes of varying heights, as seen in the first half of the rhythm strip, but this rhythm deteriorated very quickly.<span style="mso-spacerun: yes;">&nbsp;</span></span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">Learning Points:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 12.0pt;">This patient was dramatically symptomatic, but her ECG signs of M.I. might have seemed subtle to the inexperienced viewer.<span style="mso-spacerun: yes;">&nbsp; </span>It is important to be very systematic in looking at ECGs, and ST changes particularly.<span style="mso-spacerun: yes;">&nbsp; </span>The ECG machine aided us by measuring ST elevations and depressions, and it is easily seen that these signs occur in “related leads”.<span style="mso-spacerun: yes;">&nbsp; </span>Localization of ST elevation is a very accurate sign of <strong>ACUTE ST ELEVATION M.I. <span style="mso-spacerun: yes;">&nbsp;&nbsp;</span></strong>Additional leads should probably be done after the standard 12.<span style="mso-spacerun: yes;">&nbsp; </span>RVMI is rare in anterior wall M.I., as the RV is supplied by the right coronary artery, and the anterior LV wall is usually supplied by the left anterior descending artery.<span style="mso-spacerun: yes;">&nbsp; </span>Posterior leads can confirm posterior wall M.I. if it is suspected by the presence of ST <em>depression</em> in V1 – V3.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><span style="font-size: 12.0pt;">There was some discussion about whether the sudden-onset wide-complex tachycardia could be <a href="https://emedicine.medscape.com/article/1950863-overview">Torsades de pointes</a>.<span style="mso-spacerun: yes;">&nbsp; </span>TdP can only be diagnosed in the setting of <strong>long QTc</strong>, which was not noted in the first two ECGs.<span style="mso-spacerun: yes;">&nbsp; </span><a href="https://pubmed.ncbi.nlm.nih.gov/11583899/">Polymorphic VT in the setting of acute M.I. is usually associated with ischemia, not QT prolongation.</a><span style="mso-spacerun: yes;">&nbsp; </span>It can be very hard to determine the point at which polymorphic VT becomes V Fib, but clinically, it does not matter.<span style="mso-spacerun: yes;">&nbsp; </span>The patient needs to be defibrillated.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal;" align="left"><strong><span style="font-size: 12.0pt; color: #538135; mso-themecolor: accent6; mso-themeshade: 191;">Follow up:</span></strong><span style="font-size: 12.0pt;"><span style="mso-spacerun: yes;">&nbsp; </span>The patient was taken to the cath lab within 45 minutes of EMS patient contact. She was found to have a proximal 100% occlusion of the left anterior descending branch. Angioplasty was successful, and we have no further information.</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--6" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--12" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Acute Anterior M.I. and Ventricular Fibrillation 1/5</option><option value="40">Give Acute Anterior M.I. and Ventricular Fibrillation 2/5</option><option value="60">Give Acute Anterior M.I. and Ventricular Fibrillation 3/5</option><option value="80" selected="selected">Give Acute Anterior M.I. and Ventricular Fibrillation 4/5</option><option value="100">Give Acute Anterior M.I. and Ventricular Fibrillation 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.7</span></span> <span class="total-votes">(<span >6</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-_ayS1CKP-UOYBB2W408fV3_WzpT7ob_pyAgNYi2Ibl4" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/awmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AWMI</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/ventricular-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular fibrillation</a></div><div class="field-item odd"><a href="/ecg/v-fib-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">V Fib</a></div><div class="field-item even"><a href="/ecg/hyperacute-t-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperacute T waves</a></div><div class="field-item odd"><a href="/ecg/defibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Defibrillation</a></div><div class="field-item even"><a href="/ecg/cath-lab-images" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Cath lab images</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_6"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Facute-anterior-mi-and-ventricular-fibrillation&amp;title=%20Acute%20Anterior%20M.I.%20and%20Ventricular%20Fibrillation"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 04 Apr 2023 21:11:57 +0000 Dawn 837 at https://www.ecgguru.com https://www.ecgguru.com/ecg/acute-anterior-mi-and-ventricular-fibrillation#comments Widespread ST Elevation With Right Bundle Branch Block https://www.ecgguru.com/ecg/widespread-st-elevation-right-bundle-branch-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Rescue%201%20Edit%20GURU.jpg" width="1800" height="325" alt="" /></a></div><div class="field-item odd"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Rescue%202%20Edit%20Guru.jpg" width="1800" height="344" alt="" /></a></div><div class="field-item even"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20ECG%203%20Hosp%201%20Edit%20GURU.jpg" width="1800" height="1393" alt="" /></a></div><div class="field-item odd"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Hosp%202%20ECG%204%20Edit.jpg" width="1800" height="1384" alt="" /></a></div><div class="field-item even"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Hosp%203%20ECG%205%20Rt%20Precord%20Edit%20GURU.jpg" width="1800" height="1356" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left">Usually, instructors of basic ECG classes look for examples of the most common conditions that are likely to be encountered by the learners.<span style="mso-spacerun: yes;">&nbsp; </span>But, sometimes, it is advantageous to show students more unusual presentations to remind them of the infinite possibilities when we care for living beings.<span style="mso-spacerun: yes;">&nbsp; </span>This series is a very good example of what can and does happen to some people with cardiovascular disease.<span style="mso-spacerun: yes;">&nbsp; </span>It will give your students an opportunity to think about possible interpretations, and also about anticipating clinical implications and emergencies that may arise.<strong></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The Patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>This patient is a man in his 80s who has been active his whole life.<span style="mso-spacerun: yes;">&nbsp; </span>He considers himself to be healthy, giving no medical history and denying medication use. He states that he has had a yearly health exam.<span style="mso-spacerun: yes;">&nbsp; </span>Today, he felt “tired and dizzy” while raking leaves.<span style="mso-spacerun: yes;">&nbsp; </span>As he walked to his house to rest, he had a syncopal episode and fell, hitting his head. He was unconscious for a few minutes. A family member called for Emergency Medical Services (EMS). Paramedics found him awake and complaining of bilateral “shoulder and wrist” pain. He had no obvious trauma to his extremities, but had some bruising on his head and face.<span style="mso-spacerun: yes;">&nbsp; </span>He denied recent illness and substance abuse.<span style="mso-spacerun: yes;">&nbsp; </span>He was oriented x3. He was pale and diaphoretic, and complained of nausea. He denied chest or back pain.<span style="mso-spacerun: yes;">&nbsp; </span>He denied shortness of breath.<span style="mso-spacerun: yes;">&nbsp; </span>BP 100/60.<span style="mso-spacerun: yes;">&nbsp; </span>Heart rate bradycardic.<span style="mso-spacerun: yes;">&nbsp; </span>SPO2 above 95%.<span style="mso-spacerun: yes;">&nbsp; </span>He was given aspirin and ondasetron, and transported to a hospital.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The first ECG</span></strong>was taken on arrival of the paramedics.<span style="mso-spacerun: yes;">&nbsp; </span>We see:<span style="mso-spacerun: yes;">&nbsp; </span><strong>sinus bradycardia</strong> at 42 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The PR interval is normal at 180 ms.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS duration is 158 ms and there is <strong>right bundle branch block</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong>frontal plane axis is normal</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong>inferior wall leads</strong>, II, III, and aVF have marked ST elevation, along with T wave inversion.<span style="mso-spacerun: yes;">&nbsp; </span>The ST elevation is due to transmural ischemia (STEMI).<span style="mso-spacerun: yes;">&nbsp; </span>This finding is backed up by the ST depression in I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>Reciprocal ST depression confirms that the STE in the inferior leads is due to M.I.</p><p class="MsoNormal" style="text-align: left;" align="left">Another unwelcome finding is in the precordial leads.<span style="mso-spacerun: yes;">&nbsp; </span>V<sub>1</sub> has a small ST elevation, plus a straight ST segment and flat T wave.<span style="mso-spacerun: yes;">&nbsp; </span>V<sub>2</sub> through V<sub>5</sub> have very pronounced ST elevation with a straight shape, and V<sub>6</sub> has a more subtle version of the same thing.<span style="mso-spacerun: yes;">&nbsp; </span>So, this looks like an acute coronary event happening simultaneously in the inferior and anterior walls!</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The second ECG</span></strong>was taken enroute to the hospital. According to the paramedics, the electrodes were not changed, and the patient’s position was not changed drastically.<span style="mso-spacerun: yes;">&nbsp; </span>Now, we see a heartrate of 51 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>Still slow, but slightly better. The inferior leads now have no STE, although the shape of the ST segment is flat and straight (not good).<span style="mso-spacerun: yes;">&nbsp; </span>We also do not see reciprocal STD in I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>Could this be a return of blood flow to the inferior wall?<span style="mso-spacerun: yes;">&nbsp; </span>Or an electrode position or patient position issue? The frontal plane axis has shifted to the left. Again, position, or onset of left anterior hemiblock? There is still STE in V<sub>1</sub>, V<sub>2</sub>, and V<sub>3</sub>, although the lateral chest leads look improved.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The third ECG</span></strong>was taken in the hospital, upon arrival of the patient.<span style="mso-spacerun: yes;">&nbsp; </span>The rate is 48 bpm, and we still see sinus bradycardia with RBBB.<span style="mso-spacerun: yes;">&nbsp; </span>This ECG looks very similar to the second field ECG.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The fourth ECG</span></strong>was taken ten minutes after the third. Now, we see a return to STEMI patterns in both inferior and anterior walls. Leads II, III, and aVF show us blatant STE, with corroborating reciprocal ST depression in I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>There is even reciprocal depression in V<sub>1</sub> and V<sub>2</sub>, a common finding in inferior wall MI, indicating extension of the transmural injury up the posterior wall.<span style="mso-spacerun: yes;">&nbsp; </span>In the first field ECG, this sign was obliterated by the STE in those leads.<span style="mso-spacerun: yes;">&nbsp; </span>There is STE in V<sub>3</sub>- V<sub>5</sub>, with ST flattening in V<sub>6</sub>.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The fifth ECG</span></strong>was taken with the chest leads placed on the right side of the chest.<span style="mso-spacerun: yes;">&nbsp; </span>That is, V<sub>1</sub> and V<sub>2</sub> wires were switched, and V<sub>3 </sub>through V<sub>6</sub> are in the usual anatomical positions, except on the patient’s right chest.<span style="mso-spacerun: yes;">&nbsp; </span>We now see marked STE in V<sub>3</sub>Rt through V<sub>6</sub>Rt.<span style="mso-spacerun: yes;">&nbsp; </span><strong>Right ventricular MI.</strong><strong><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">What do you make of all of this?</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>There are several options, even after ruling out electrode placement issues.<span style="mso-spacerun: yes;">&nbsp; </span>The patient has remained awake and alert, although bradycardic and symptomatic. The answers will lie in the findings in the cath lab.<span style="mso-spacerun: yes;">&nbsp; </span>If the patient has typical coronary artery anatomy and distribution, I would guess that these ECGs represent severe triple vessel disease, with some lesions that are not 100% occlusive.<span style="mso-spacerun: yes;">&nbsp; </span>That is, as the arteries dilate, blood flow would improve – when they constrict, blood flow would be affected, and the ECG would reflect this perfusion change.<span style="mso-spacerun: yes;">&nbsp; </span>There are many possibilities other than this to consider: “Type 2 M.I”, which is ischemia due to an overall perfusion drop due to a medical or trauma condition; coronary artery spasm; or unusual configuration of the coronary arteries. Occasionally, angiograms reveal an extremely dominant artery that is responsible for most of the heart. There may be a “wrap around” LAD, which wraps around the apex of the left ventricle, perfusing the inferior wall along with the anterior wall.<span style="mso-spacerun: yes;">&nbsp; </span>There are even instances of only one coronary artery arising from the aorta, with the other being a branch of the first. So there might be only one branch from the aorta.<span style="mso-spacerun: yes;">&nbsp; </span>For example, the LCA might be the only coronary artery branching off the aorta, with the RCA being a branch off the LCA.<span style="mso-spacerun: yes;">&nbsp; </span>A proximal lesion would affect all parts of the heart.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">Patient follow up:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>The patient had a cardiac cath.<span style="mso-spacerun: yes;">&nbsp; </span>He was found to have severe multi-vessle disease with the following lesions:<span style="mso-spacerun: yes;">&nbsp; </span>Right coronary artery, 99% occlusive lesion. Proximal left coronary artery, 40% lesion.<span style="mso-spacerun: yes;">&nbsp; </span>Left anterior descending coronary artery, 75% lesion.<span style="mso-spacerun: yes;">&nbsp; </span>He was successfully cardioverted from ventricular tachycardia once, and was placed on a balloon pump (we do not know his EF at the time of the cath).<span style="mso-spacerun: yes;">&nbsp; </span>He declined CABG surgery, and was evaluated for possible percutaneous intervention. We do not have further information.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left"><em><span style="font-size: 9.0pt; line-height: 107%; color: #385623; mso-themecolor: accent6; mso-themeshade: 128;">Our thanks to Timothy Chopelas for donating this case.</span></em></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--7" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--14" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Widespread ST Elevation With Right Bundle Branch Block 1/5</option><option value="40">Give Widespread ST Elevation With Right Bundle Branch Block 2/5</option><option value="60">Give Widespread ST Elevation With Right Bundle Branch Block 3/5</option><option value="80" selected="selected">Give Widespread ST Elevation With Right Bundle Branch Block 4/5</option><option value="100">Give Widespread ST Elevation With Right Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.7</span></span> <span class="total-votes">(<span >10</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--7" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-emmnsAObR4A0I-ZxlJgkYgsm5eT-rFZAvsn51uXoBNg" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item even"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item odd"><a href="/ecg/posterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Posterior M.I.</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_7"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fwidespread-st-elevation-right-bundle-branch-block&amp;title=Widespread%20ST%20Elevation%20With%20Right%20Bundle%20Branch%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 04 Feb 2023 16:22:21 +0000 Dawn 836 at https://www.ecgguru.com https://www.ecgguru.com/ecg/widespread-st-elevation-right-bundle-branch-block#comments Inferior Wall M.I. In A Patient With Left Bundle Branch Block https://www.ecgguru.com/ecg/inferior-wall-mi-patient-left-bundle-branch-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-patient-left-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/070317%20LBBB%20MI%20Ed_0.jpg" width="1800" height="713" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">A 64-year-old man complaining of chest pain and shortness of breath for 20 minutes.<span style="mso-spacerun: yes;">&nbsp; </span>Long-standing history of triple vessel disease, severe aortic stenosis, hypertension, thrombocytopenia.<span style="mso-spacerun: yes;">&nbsp; </span>Meds unknown.<span style="mso-spacerun: yes;">&nbsp; </span>He was not considered to be a candidate for valve surgery.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The ECG: </span></strong><span style="font-size: 12.0pt; line-height: 107%;">There is <strong>normal sinus rhythm</strong> with a rate of 90 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>P waves are not visualized well in all leads, so remember that the three channels of this ECG are run simultaneously.<span style="mso-spacerun: yes;">&nbsp; </span>If you see a P wave in Leads I and II, they are also present in Lead III.<span style="mso-spacerun: yes;">&nbsp; </span>The PR interval is WNL.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%;">The QRS complexes are <strong>wide</strong>, at .122 seconds (122 ms).<span style="mso-spacerun: yes;">&nbsp; </span>The criteria for <strong>left bundle branch</strong> <strong>block</strong> are met. (Supraventricular rhythm, wide QRS, upright QRS in Leads I and V6, negative QRS in V1).<span style="mso-spacerun: yes;">&nbsp; </span>The frontal plane axis is within normal limits, but toward the right, at 87 degrees.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS complexes transition at V4 from negative to positive, but Leads V1 – V3 have no initial r waves.<span style="mso-spacerun: yes;">&nbsp; </span>These are possibly&nbsp;</span><span style="font-size: 12pt;">pathological Q waves, likely from a past anterior-septal M.I.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%;">In left bundle branch block, and most other conditions that cause wide QRS, there will normally be ST changes.<span style="mso-spacerun: yes;">&nbsp; </span>The ST segments will deviate from the baseline in a direction <em>opposite,</em> or <em>discordant</em>, from the QRS.<span style="mso-spacerun: yes;">&nbsp; </span>So, all leads with a wide, upright QRS should have some ST depression.<span style="mso-spacerun: yes;">&nbsp; </span>All leads with a wide, downward-deflected QRS should have some ST elevation.<span style="mso-spacerun: yes;">&nbsp; </span>Further, this <em>ST change is proportionate to the size of the QRS complex.</em><span style="mso-spacerun: yes;">&nbsp; </span><span style="mso-spacerun: yes;">&nbsp;</span>A TALL or DEEP QRS will be accompanied by more ST depression or elevation, while a small or <span style="mso-spacerun: yes;">&nbsp;</span>biphasic QRS may show no ST deviation at all.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%;">Because there is normally ST segment deviation with left bundle branch block, it can be tricky to recognize acute coronary syndromes, like M.I. or STEMI.<span style="mso-spacerun: yes;">&nbsp; </span>In 1996, <a href="https://www.mdcalc.com/calc/1732/sgarbossas-criteria-mi-left-bundle-branch-block">Dr. Elena Sgarbossa</a> first described criteria to help clinicians determine the presence of ACS in the presence of wide QRS.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%;">She did not have the advantage of cath lab results to confirm her findings, but the criteria were very useful.<span style="mso-spacerun: yes;">&nbsp; </span>In 2012, Dr. Stephen Smith, et al, published a <a href="https://pubmed.ncbi.nlm.nih.gov/22939607/">modified version of the Sgarbossa Criteria. </a><span style="mso-spacerun: yes;">&nbsp;</span>Their research included definitive cath lab findings.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%;">This ECG shows definite signs of acute myocardial transmural injury (STEMI).<span style="mso-spacerun: yes;">&nbsp; </span>The inferior leads, II, III, and aVF, have ST elevation which is CONCORDANT with the direction of the QRS.<span style="mso-spacerun: yes;">&nbsp; </span>Remember, in LBBB, the ST should be discordant, or opposite, the direction of the QRS.<span style="mso-spacerun: yes;">&nbsp; </span>Leads I and aVL show concordant ST depression, a reciprocal change seen in inferior wall M.I.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">Patient Outcome: <span style="mso-spacerun: yes;">&nbsp;</span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">As noted above, this patient had an extensive medical history.<span style="mso-spacerun: yes;">&nbsp; </span>On admission, he was determined to be in multi-organ failure.<span style="mso-spacerun: yes;">&nbsp; </span>He was scheduled for a cath to determine the extent of his cardiac disease and to help develop a treatment plan.<span style="mso-spacerun: yes;">&nbsp; </span>In the pre-procedure area, the patient deteriorated, developed acute respiratory failure, was intubated, and succumbed to his disease without having the procedure. </span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><em><span style="font-size: 9.0pt; line-height: 107%;">Our thanks to Sebastian Garay for donating this case.</span></em></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--8" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--16" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Wall M.I. In A Patient With Left Bundle Branch Block 1/5</option><option value="40">Give Inferior Wall M.I. In A Patient With Left Bundle Branch Block 2/5</option><option value="60">Give Inferior Wall M.I. In A Patient With Left Bundle Branch Block 3/5</option><option value="80" selected="selected">Give Inferior Wall M.I. In A Patient With Left Bundle Branch Block 4/5</option><option value="100">Give Inferior Wall M.I. In A Patient With Left Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >60</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-5OO4tMQQwQKnj_qNx-Aiw2_Cv3gfPHiXdqypHt9iCpA" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div><div class="field-item even"><a href="/ecg/left-bundle-branch-block-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left bundle branch block</a></div><div class="field-item odd"><a href="/ecg/sgarbossas-criteria" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sgarbossa&#039;s Criteria</a></div><div class="field-item even"><a href="/ecg/smith-modified-sgarbossa-criteria-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Smith-modified Sgarbossa Criteria</a></div><div class="field-item odd"><a href="/ecg/lbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">LBBB</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_8"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-wall-mi-patient-left-bundle-branch-block&amp;title=Inferior%20Wall%20M.I.%20In%20A%20Patient%20With%20Left%20Bundle%20Branch%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 23 Dec 2022 20:24:46 +0000 Dawn 819 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-patient-left-bundle-branch-block#comments Inferior Wall, Posterior Wall, and Right Ventricular M.I. https://www.ecgguru.com/ecg/inferior-wall-posterior-wall-and-right-ventricular-mi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-posterior-wall-and-right-ventricular-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/082222%20IWMI%20PWMI%20RVMI%201%20Ed_0.jpg" width="1263" height="455" alt="" /></a></div><div class="field-item odd"><a href="/ecg/inferior-wall-posterior-wall-and-right-ventricular-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/082222%20IWMI%20PWMI%20RVMI%202%20Ed.jpg" width="1245" height="479" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp; </span></span>79-year-old man complaining of severe “burning” chest pain, radiating to his neck. Walking exacerbates his discomfort.<span style="mso-spacerun: yes;">&nbsp; </span>He has had nausea and vomiting for 24 hours. Past medical Hx includes high cholesterol and atrial fibrillation. Medications not known.</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The ECGs</span>:</strong><span style="mso-spacerun: yes;">&nbsp; </span>These ECGs could be called “classic”.<span style="mso-spacerun: yes;">&nbsp; </span>There is a 100% occlusion of the right coronary artery (RCA), which was successfully repaired in the cath lab.<span style="mso-spacerun: yes;">&nbsp; </span>About 80% of inferior wall M.I.s are due to occlusion of the <strong>right coronary artery</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Depending on how proximal the occlusion is, we can expect a pattern on the ECG representing injury to all areas supplied by the RCA.<span style="mso-spacerun: yes;">&nbsp; </span>This “package deal” can include:</p><p class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;</span>Inferior wall ST elevation.</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;</span>Posterior wall extension.</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;</span>Right ventricular M.I.</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;</span>Right atrial ischemia, including damage to the SA and AV nodes.</span></p><p class="MsoListParagraphCxSpLast" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;</span>Occasionally, low lateral wall ST elevation, when that area is solely perfused by the RCA.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 9.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">ECG No. 1,</span></strong><strong>obtained at 5:34 am, shows the following:</strong></p><p class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -.25in; mso-list: l1 level1 lfo2;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Atrial fibrillation with a slow ventricular response. (AV node may be ischemic).</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l1 level1 lfo2;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">ST elevation in Leads II, III, aVF, V<sub>4</sub>, V<sub>5</sub>, and V<sub>6</sub>. (Transmural injury in the inferior and low lateral wall).</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l1 level1 lfo2;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Reciprocal ST depression in I and aVL. (Leads reciprocal to inferior wall).</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l1 level1 lfo2;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Reciprocal ST depression in V<sub>1</sub>, V<sub>2</sub>, and V<sub>3</sub>. (Leads reciprocal to posterior wall).</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l1 level1 lfo2;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Hyperacute T waves in leads with STE (often a sign that precedes the STE).</span></p><p class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -.25in; mso-list: l1 level1 lfo2;" align="left"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">STE in Lead III is greater than STE in Lead II.<span style="mso-spacerun: yes;">&nbsp; </span>STD in V<sub>1</sub> minimal, compared to V<sub>2</sub>. (These are reliable signs that there is right ventricular M.I.)</span></p><p class="MsoListParagraphCxSpLast" style="text-align: left;" align="left"><span style="font-size: 10.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left">From this list of ECG signs, we can say that there is <strong>INFERIOR WALL ST ELEVATION M.I</strong>., plus likely <strong>RIGHT VENTRICULAR M.I.</strong> and <strong>POSTERIOR WALL EXTENSION OF IWMI</strong>.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">ECG No. 2</span></strong>, <strong>obtained at 5:37 a.m., has an additional lead: </strong><span style="mso-spacerun: yes;">&nbsp;</span><strong><span style="color: #00b050;">V<sub>4</sub> Right</span></strong>.<span style="mso-spacerun: yes;">&nbsp; </span>V<sub>4</sub>R shows ST elevation, with a flat ST segment and T wave inversion.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong>right ventricular M.I.</strong> has been confirmed.<span style="mso-spacerun: yes;">&nbsp; </span>(Note:<span style="mso-spacerun: yes;">&nbsp; </span>Posterior wall M.I. could be confirmed with posterior leads, V<sub>7</sub>, V<sub>8</sub>, V<sub>9</sub>. We do not have those here.)</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left">Inferior wall M.I. has a relatively low mortality rate, usually less than 10%.<span style="mso-spacerun: yes;">&nbsp; </span>However, the presence of RVMI increases the chance of hypotensive episodes and in-hospital mortality by up to half.<span style="mso-spacerun: yes;">&nbsp; </span>RVMI does not change mortality rates after hospital discharge. In addition, the posterior wall extension indicates that this M.I. is a large one, from a proximal occlusion of the RCA.</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">Summary:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span>Being able to quickly recognize this pattern will help you spot IWMI even before the ST elevations are large.<span style="mso-spacerun: yes;">&nbsp; </span>When there is only very subtle ST elevation, the presence of the pattern of <strong>STE in the inferior leads and reciprocal STD in aVL </strong>make it easy to recognize. Reciprocal STD often shows up before STE, and is more dramatic and easier to spot.<span style="mso-spacerun: yes;">&nbsp; </span>When there is also bradycardia, posterior wall M.I., and RVMI, it becomes even easier to diagnose right coronary artery occlusion.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--9" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--18" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Wall, Posterior Wall, and Right Ventricular M.I. 1/5</option><option value="40">Give Inferior Wall, Posterior Wall, and Right Ventricular M.I. 2/5</option><option value="60">Give Inferior Wall, Posterior Wall, and Right Ventricular M.I. 3/5</option><option value="80" selected="selected">Give Inferior Wall, Posterior Wall, and Right Ventricular M.I. 4/5</option><option value="100">Give Inferior Wall, Posterior Wall, and Right Ventricular M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >71</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--9" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-cIsahslIleJS6BLQ4vdpKQHn-fhqTZSJZlv8Yhvknrw" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/reciprocal-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal changes</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/right-ventricular-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right ventricular M.I.</a></div><div class="field-item odd"><a href="/ecg/posterior-wall-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Posterior wall M.I.</a></div><div class="field-item even"><a href="/ecg/right-coronary-artery-occlusion" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right coronary artery occlusion</a></div><div class="field-item odd"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_9"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-wall-posterior-wall-and-right-ventricular-mi&amp;title=Inferior%20Wall%2C%20Posterior%20Wall%2C%20and%20Right%20Ventricular%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 11 Sep 2022 22:19:23 +0000 Dawn 818 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-posterior-wall-and-right-ventricular-mi#comments Large Anterior Wall M.I. and Effect of Lead Reversal https://www.ecgguru.com/ecg/large-anterior-wall-mi-and-effect-lead-reversal <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/large-anterior-wall-mi-and-effect-lead-reversal"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Prox%20LAD%20MI%201%20edit.jpg" width="2227" height="1287" alt="" /></a></div><div class="field-item odd"><a href="/ecg/large-anterior-wall-mi-and-effect-lead-reversal"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Prox%20LAD%20MI%202_0.jpg" width="1860" height="1230" alt="" /></a></div><div class="field-item even"><a href="/ecg/large-anterior-wall-mi-and-effect-lead-reversal"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Cath%20lab%20photos%20before%20and%20after_0.jpg" width="1601" height="738" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong>EDIT: Please refer to the comments below this text. The second ECG in this series shows unexpected QRS and ST-T morphology changes, which I tried to explain by way of the patient's long anterior descending coronary artery. However, Dave Richley, who is a very well-known cardiac physiologist and ECG Guru took the time to analyze these morphologies and realize they can be explained by an inadvertent ECG LEAD MISPLACEMENT. This patient does have a proximal lesion of the LAD, proven and repaired in the cath lab. But the inferior wall does not have the injury it appears to have in this second ECG. Thanks to Dave for reminding us to slow down and look closely when things don't look "right".</strong></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">These two ECGs, taken 26 minutes apart, were obtained from a 50-year-old man who complained of sudden onset of chest pain.<span style="mso-spacerun: yes;">&nbsp; </span>He denied history of coronary artery disease. He was Covid-positive, and the rest of his medical history was unremarkable.</span></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">ECG No. 1:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 10.0pt; line-height: 107%;">This ECG was obtained by paramedics enroute to the hospital.<span style="mso-spacerun: yes;">&nbsp; </span>For your beginner-level students, it will be easy to demonstrate the large ST elevations in V3 through V6. The machine’s measurements at the bottom confirm that this ECG meets any field criteria for ST elevation M.I. “STEMI”.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">But there is so much more to see! Taking a methodical approach, and starting with rate and rhythm, we see <strong>sinus bradycardia </strong>at 57 bpm. Intervals and frontal plane axis are within normal limits. R wave progression in the chest leads is stalled in V1- V3 due to loss of initial r waves (narrow QS). The transition to positive deflections in V4 – V6 is abrupt.<span style="mso-spacerun: yes;">&nbsp; </span>These q waves in the V1 and V2 appear narrow, but V3 appears to have a Q wave that is almost wide enough to be considered pathological.<span style="mso-spacerun: yes;">&nbsp; </span>Narrow Q waves may be a transient sign of injury, while wide ones (&gt;40 ms) are an ECG sign of necrosis. </span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">A very visible finding on this ECG is the <strong><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500486/">hyperacute T waves</a></strong>. Hyperacute T waves are defined by comparison to the patient’s normal T waves, if possible. But a general description is broad-based, symmetrical T waves that are unusually tall in comparison to the QRS complex and to the patient’s previous T waves. In this tracing, we see hyperacute T waves in just about all leads.<span style="mso-spacerun: yes;">&nbsp; </span>Hyperacute T waves are a very early sign of subendocardial ischemia in a patient with coronary artery occlusion, and the sign doesn’t last long.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">This patient is already progressing to the next ECG stage of ischemia and injury:<span style="mso-spacerun: yes;">&nbsp; </span><strong>ST segment elevation</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>There is elevation in V2 through V6, I and aVL, and very slightly in Leads II and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>In addition to this J point elevation, many ST segments have a flat, horizontal shape, which is an abnormal sign, indicative of ischemia. Leads III and aVF are good examples of this abnormal ST segment shape.<span style="mso-spacerun: yes;">&nbsp;</span></span><span style="font-size: 10pt;">V1 has </span>an inverted T wave<span style="font-size: 10pt;">.</span><span style="mso-spacerun: yes;">&nbsp; V2 shows the T wave transition to upright.&nbsp;&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 13.3333px;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">ECG No. 2:</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">This ECG was taken in the Emergency Department, 26 minutes after the first one.<span style="mso-spacerun: yes;">&nbsp; </span>The rate and intervals have not changed much.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS duration has lengthened by .04 seconds, the QTc has prolonged by 26 ms.<span style="mso-spacerun: yes;">&nbsp; </span>The axis has shifted slightly to the left, but still within normal limits.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">Leads II, III, and aVF (inferior wall) have lost voltage and gained quite noticeable ST segment elevation.<span style="mso-spacerun: yes;">&nbsp; </span>Lead III has a narrow Q wave and biphasic T wave, which are new developments.<span style="mso-spacerun: yes;">&nbsp; </span>Leads I and aVL are now so influenced by the STE in the inferior wall, they show ST depression, which is reciprocal to the elevation in the inferior leads.&nbsp;<span style="mso-spacerun: yes;">&nbsp;</span>It has obliterated the ST elevation in those leads, but we remember it is there!</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">Lead V1 has developed concave-down elevation (the “frown”), and has a narrow Q wave.<span style="mso-spacerun: yes;">&nbsp; </span>V2 and V3 have enhanced ST elevation, and the Q waves in those leads have widened to greater than 40 ms. <span style="mso-spacerun: yes;">&nbsp;</span>Leads V5 and V6 have less ST elevation, possibly influenced by simultaneous reciprocal ST depression.<span style="mso-spacerun: yes;">&nbsp; </span>We can say that this M.I. has definitely progressed, and it is <strong>VERY large</strong>.</span></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">Follow Up:</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">The patient was taken very quickly to the cath lab, where it was found that he had a proximal LAD occlusion from a fresh clot.<span style="mso-spacerun: yes;">&nbsp; </span>The other arteries showed no signs of CAD.<span style="mso-spacerun: yes;">&nbsp; </span>You might be thinking, “that explains the changes in the chest leads (anterior wall), but how is the inferior wall involved in this M.I.?”<span style="mso-spacerun: yes;">&nbsp; </span>This patient is one of the many people (up to 79% of the population) who has a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528515/">wrap-around LAD</a>.<span style="mso-spacerun: yes;">&nbsp; </span>That is, it perfuses the apex of the left ventricle.<span style="mso-spacerun: yes;">&nbsp; </span>Approximately one fourth of the population has an LAD that wraps around <strong>more than one fourth</strong> of the inferior wall. This type of LAD predicts additional risk of adverse clinical outcomes for M.I. patients because of the large amount of territory covered by this wrap-around artery.<span style="mso-spacerun: yes;">&nbsp; </span>The patient arrived in the cath lab before his troponin levels went up, and had a successful procedure.<span style="mso-spacerun: yes;">&nbsp; </span>He is lost to follow up after that.<span style="mso-spacerun: yes;">&nbsp;&nbsp;</span></span></p><p>&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/133/feed" method="post" id="fivestar-custom-widget--10" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--20" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Large Anterior Wall M.I. and Effect of Lead Reversal 1/5</option><option value="40">Give Large Anterior Wall M.I. and Effect of Lead Reversal 2/5</option><option value="60">Give Large Anterior Wall M.I. and Effect of Lead Reversal 3/5</option><option value="80" selected="selected">Give Large Anterior Wall M.I. and Effect of Lead Reversal 4/5</option><option value="100">Give Large Anterior Wall M.I. and Effect of Lead Reversal 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.1</span></span> <span class="total-votes">(<span >67</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--10" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-amHeKz2yOzb52TGroLYax9tHgiXFH-qgJ_fCOqjfs8I" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/lead-reversal" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Lead reversal</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/awmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AWMI</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div><div class="field-item even"><a href="/ecg/lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Lateral M.I.</a></div><div class="field-item odd"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item even"><a href="/ecg/proximal-occlusion-lad" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Proximal occlusion of LAD</a></div><div class="field-item odd"><a href="/ecg/hyperacute-t-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperacute T waves</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_10"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Flarge-anterior-wall-mi-and-effect-lead-reversal&amp;title=Large%20Anterior%20Wall%20M.I.%20and%20Effect%20of%20Lead%20Reversal%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 23 May 2022 21:52:02 +0000 Dawn 814 at https://www.ecgguru.com https://www.ecgguru.com/ecg/large-anterior-wall-mi-and-effect-lead-reversal#comments