ECG Guru - Instructor Resources - Inferior-lateral M.I. https://www.ecgguru.com/ecg/inferior-lateral-mi en Inferior Wall M.I. With Wide QRS and Complete AV Block https://www.ecgguru.com/ecg/inferior-wall-mi-wide-qrs-and-complete-av-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-wide-qrs-and-complete-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%20LBBB%20101_0.jpg" width="1800" height="802" alt="" /></a></div><div class="field-item odd"><a href="/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%20WC%20101%20Follow%20up%20post%20cath.jpg" width="453" height="132" 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><span style="font-size: 13.008px;">This ECG is from a 66-year-old woman who called 911 for a complaint of chest pain for the past four hours. She also complained of nausea, vomiting, and diarrhea for that time.</span><span style="font-size: 13.008px;">&nbsp;She was pale and diaphoretic, and her BP was 77/43 sitting up, improving to 90/54 reclining.&nbsp;</span><span style="font-size: 13.008px;">She denied “cardiac” history.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">Her medications included:</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">aspirin, an SSRI, cilostazol, amlodipine, umeclidinium and vilanterol inhaler, atorvastatin, levothyroid, and metoprolol. We don’t have a previous ECG.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">The EMS crew followed their chest pain protocol and delivered the patient to a facility with an interventional cath lab, but they did not designate a “STEMI Alert” because of the wide QRS.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">It is their protocol to use the term “STEMI Alert” only when no M.I. mimics, such as left bundle branch block, are present.</span><span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal"><strong>What does this ECG show? &nbsp;&nbsp;&nbsp;&nbsp;</strong>There is an underlying sinus rhythm at 75 bpm.&nbsp; There is AV dissociation, with regular, wide QRS complexes at a rate of 44 bpm.&nbsp; &nbsp;This meets the criteria for complete heart block (third-degree AV block).&nbsp; The morphology of the QRS complexes meets the criteria for left bundle branch block (wide, upright in Leads I and V6, negative in V1).&nbsp; At a rate of 44 bpm, several options for this escape rhythm are possible:&nbsp; 1)&nbsp; junctional escape with LBBB, 2) junctional escape with intraventricular conduction delay due to AMI,&nbsp; and 3) idioventricular escape rhythm.&nbsp; &nbsp;Also, in the presence of IWMI, AV node ischemia is very likely, resulting in AV blocks at the level of the AV node. &nbsp;CHB at the AV node would result in junctional escape rhythm, and CHB below that, in the fascicles of the bundle branches, would result in idioventricular escape. The issue for this patient, and ANY patient, is cardiac output, and we see several reasons for cardiac output to be lower:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Wide QRS</strong></p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Slow rate</strong></p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Lack of P waves preceding every QRS (loss of atrial kick).</strong></p><p class="MsoNormal">In the EMS setting, it really doesn’t matter if the escape rhythm is junctional with wide QRS or ventricular. &nbsp;The patient's hemodynamic status is the important consideration.</p><p class="MsoNormal"><strong>Even more alarming, </strong>this ECG shows signs of acute inferior wall M.I.&nbsp; It can be difficult to ascertain when STEMI is present in the presence of wide-complex rhythms.&nbsp; That is because most wide-complex rhythms have <em>discordant ST and T wave changes.</em>&nbsp; That is, whenever the wide QRS is positive, there is ST depression and T wave inversion, and whenever the wide QRS is negative, there is ST elevation and upright T waves.</p><p class="MsoNormal">This ECG shows excessively elevated discordant ST segments in the inferior leads (II, III, and aVF.)&nbsp; We also see <em>excessively discordant&nbsp;</em>ST elevation in V3, and V4. The change from ST depression to ST elevation between V2 and V3 is very abrupt, with the obvious ST depression in V1 and V2 indicating reciprocal views of ST elevation on the posterior wall. &nbsp;In LBBB without STEMI, there is normally ST elevation in V1 a V3.</p><p class="MsoNormal"><strong>Sgarbossa and Smith</strong>&nbsp;&nbsp;&nbsp; In 1996, Sgarbossa, et al proposed a univariate scoring system for determining acute M.I. in the presence of LBBB.&nbsp; <a href="https://lifeinthefastlane.com/ecg-library/basics/sgarbossa/">Sgarbossa’s Criteria</a> has been used for with some success both in the presence of LBBB and ventricular paced rhythms.&nbsp; These criteria were formulated before results could be confirmed with cath lab results.&nbsp; In this decade, Dr. Steven Smith and his colleagues have proposed some <a href="https://vimeo.com/34634434">modifications to Sgarbossa’s Criteria</a> which take into account the ratio of ST alteration to R wave. In Smith’s Modification, excessive discordance is measured as discordant ST elevation when the j point is &gt; 0.25, or 25% the depth of the S wave. &nbsp;His results have been, and continue to be, measured against cath lab findings, and are more accurate than the original criteria. &nbsp;For an excellent discussion of LBBB, Sgarbossa’s Criteria, and Smith’s modified Sgarbossa criteria, we recommend Tom’s Bouthillet’s excellent <a href="https://www.ecgmedicaltraining.com/making-sense-of-sgarbossas-criteria-chest-pain-and-left-bundle-branch-block-part-1/">three-part series</a> on the topic.</p><p class="MsoNormal">With the exception of right bundle branch block, most wide-QRS conditions are considered “mimics” of acute M.I., and can both disguise the presence of an M.I. and masquerade as M.I.&nbsp; Unfortunately, the mimics do not <em>prevent</em> the patient from having an M.I.</p><p class="MsoNormal"><strong>How did this patient do?&nbsp;&nbsp; </strong>The infero-lateral M.I. was recognized in the emergency department, and the patient’s hypotension was treated with pacing and fluids. She was sent immediately to the cath lab, where it was found that she had a single-vessel lesion in the proximal to mid right coronary artery. There was 100% occlusion with TIMI-0 flow. She underwent angioplasty and stent placement, with excellent TIMI-III results.&nbsp;<span style="font-size: 13.008px;">&nbsp;The RCA was dominant, and much larger than the LCA. The second ECG shows the excellent results of the angioplasty - QRS is narrow, the rhythm is sinus, and ST segments returning to normal. The tiny Q wave in Lead III eventually disappeared, probably because it was due to right ventricular M.I.</span></p><p class="MsoNormal">This crew felt they were following their protocol in not calling this a “STEMI Alert”, but fortunately they were able to transport the patient to a full-service cardiac hospital, where she received angioplasty very quickly.&nbsp;<strong></strong></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/553/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 Inferior Wall M.I. With Wide QRS and Complete AV Block 1/5</option><option value="40">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 2/5</option><option value="60">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 3/5</option><option value="80">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 4/5</option><option value="100" selected="selected">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.2</span></span> <span class="total-votes">(<span >5</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--t3NGQT01f3j7SmeOwLZoegsMAfQndCr43pLi1exIVY" /> <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/intraventricular-conduction-delay" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Intraventricular conduction delay</a></div><div class="field-item even"><a href="/ecg/third-degree-av-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Third-degree AV block</a></div><div class="field-item odd"><a href="/ecg/complete-heart-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete heart block</a></div><div class="field-item even"><a href="/ecg/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</a></div><div class="field-item odd"><a href="/ecg/inferior-lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-lateral 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/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/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</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%2Finferior-wall-mi-wide-qrs-and-complete-av-block&amp;title=Inferior%20Wall%20M.I.%20With%20Wide%20QRS%20and%20Complete%20AV%20Block"><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> Wed, 28 Jun 2017 20:13:14 +0000 Dawn 733 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block#comments Inferior-lateral M.I. With QRS Fragmentation https://www.ecgguru.com/ecg/inferior-lateral-mi-qrs-fragmentation <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-lateral-mi-qrs-fragmentation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW120%20fQRS%20V4R%20ECG6.jpg" width="1800" height="656" 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><span style="font-size: 12.0pt; line-height: 107%;">SUBTLE ST CHANGES&nbsp;&nbsp; </span></strong><span style="font-size: 12.0pt; line-height: 107%;">This ECG was obtained from an 87-year-old man who was experiencing chest pain.&nbsp; Due to the subtle ST elevation in Leads II, III, aVF, V<sub>5</sub>, and V<sub>6</sub>, (inferior- lateral walls) the ECG was transmitted to the hospital by the EMS crew, and the cath lab was activated.&nbsp; The patient denied previous cardiac history.</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">In addition to the subtle ST elevation, there is ST depression in V<sub>1</sub> through V<sub>4</sub>, which represents a reciprocal view of the injury in the inferior-posterior-lateral wall.&nbsp; Because the anterior wall is superior in its position in the chest, it is opposite the inferior/posterior wall, and can show ST depression when the inferior-posterior area has ST elevation. This ECG was the 6<sup>th</sup> one done during this EMS call.&nbsp; Prior to this one, the ST segments were elevated less than 1 mm. &nbsp;This is a good example of the value of repeat ECGs during an acute event.&nbsp;</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">RIGHT VENTRICULAR M.I.?&nbsp;&nbsp;&nbsp;&nbsp; </span></strong><span style="font-size: 12.0pt; line-height: 107%;">This ECG was done with V<sub>4</sub> placed on the right side, to check for right ventricular M.I., which is a protocol for this EMS agency. When the right coronary artery is the culprit artery (about 80% of IWMIs), RVMI is likely.&nbsp; In RVMI, we would usually see reciprocal ST depression in Leads I and aVL, but the STE is very subtle here, so the depression would likely be also.&nbsp; When the culprit artery is the left circumflex artery (&lt;20%), lateral lead ST elevation is more likely, as we see here in V<sub>5</sub> and V<sub>6</sub>.</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">WHAT ABOUT RHYTHM?</span></strong><span style="font-size: 12.0pt; line-height: 107%;">&nbsp;&nbsp;&nbsp; &nbsp;The rhythm is sinus with PACs.&nbsp; PACs are considered to be benign in most situations, but in a patient with acute M.I., any dysrhythmia can be concerning. The QT interval, measured as QTc (corrected to a heart rate of 60 bpm), is slightly prolonged at .458 seconds (458 ms).&nbsp; Over .440 seconds is considered prolonged in men, and over .500 sec. places the patient at increased risk of developing torsades de pointes.&nbsp; CAD and myocardial ischemia can lead to this modest increase in QTc.</span></p><p class="MsoNormal"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span><strong style="font-size: 13.008px; line-height: 1.538em;"><span style="font-size: 12.0pt; line-height: 107%;">WHY DO SOME OF THE QRS COMPLEXES HAVE “NOTCHES”?&nbsp;&nbsp;&nbsp;&nbsp; </span></strong><span style="font-size: 12pt; line-height: 107%;">Of greater importance is the <a href="http://ncbi.nlm.nih.gov/pmc/articles/PMC3443879/#!po=22.9167">fragmentation of the QRS</a> complexes (fQRS) we see here. Notice the extra notches after the R waves in Leads II and aVF, the notch after the S wave in Lead III, V<sub>5</sub> and V<sub>6</sub>.&nbsp; This “fragmentation” is a sign of a myocardial scar, and is similar to finding a pathological Q wave on the ECG.&nbsp; In a patient with a history of coronary artery disease, fQRS is often associated with ventricular dysfunction and congestive heart failure. It can indicate that conditions are favorable for the formation of re-entrant ventricular tachycardia. Fragmented QRS is more likely to appear in the setting of STEMI and NSTEMI, and less likely in unstable angina.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The patient survived post-angioplasty, and we do not know his eventual outcome.&nbsp; Our thanks to William Bond for providing this ECG.</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/553/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 Inferior-lateral M.I. With QRS Fragmentation 1/5</option><option value="40">Give Inferior-lateral M.I. With QRS Fragmentation 2/5</option><option value="60">Give Inferior-lateral M.I. With QRS Fragmentation 3/5</option><option value="80">Give Inferior-lateral M.I. With QRS Fragmentation 4/5</option><option value="100" selected="selected">Give Inferior-lateral M.I. With QRS Fragmentation 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.4</span></span> <span class="total-votes">(<span >5</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-6xeD_ExdJes0BmoSgPLwc8n2Pxo89PRLOyXG6USulqU" /> <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/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item even"><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 odd"><a href="/ecg/inferior-lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-lateral M.I.</a></div><div class="field-item even"><a href="/ecg/qrs-fragmentation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">QRS fragmentation</a></div><div class="field-item odd"><a href="/ecg/pacs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PACs</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_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-lateral-mi-qrs-fragmentation&amp;title=%20Inferior-lateral%20M.I.%20With%20QRS%20Fragmentation"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 14 Aug 2016 05:33:04 +0000 Dawn 707 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-lateral-mi-qrs-fragmentation#comments Acute Inferior-Lateral M.I. In A Patient With A Dominant Circumflex Artery https://www.ecgguru.com/ecg/acute-inferior-lateral-mi-patient-dominant-circumflex-artery <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-inferior-lateral-mi-patient-dominant-circumflex-artery"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW%20119%20Inf%20Lat%20MI%20%20Expir%20after%20cath.jpg" width="1800" height="797" 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 ECG was obtained from a patient who suffered an obstruction of the circumflex coronary artery. &nbsp;Unfortunately, he was in the approximately 15-18% of the population in whom the circumflex artery is dominant. &nbsp;That means that it connects with the posterior descending artery, perfusing not only the lateral wall of the left ventricle, but also the posterior and inferior walls. &nbsp;In this case, the obstruction is in the midportion of the artery, and the high lateral wall is spared. &nbsp;The large number of leads with ST elevation indicate the large amount of myocardium affected. &nbsp;Leads II, III, and aVF have ST elevation, as do Leads V3 through V6. &nbsp;Lead aVL has reciprocal ST depression. The T waves in the affected leads are "hyperacute", or taller than normal. &nbsp;This is usually an early change in acute M.I., and disappears after the onset of ST elevation.</p><p>It is not always easy to determine from the ECG that the circumflex artery is the culprit artery, rather than the right coronary artery, which perfuses the inferior wall in the majority of people. &nbsp;Some clues are: &nbsp;Lead III has ST elevation equal to that of Lead II, the low lateral wall (V5 and V6) are affected, and aVL has reciprocal depression but Lead I does not.</p><p>This is a very large M.I., due to the dominance of the circumflex artery. &nbsp;The patient did not survive, in spite of aggressive treatment.</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/553/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 Acute Inferior-Lateral M.I. In A Patient With A Dominant Circumflex Artery 1/5</option><option value="40">Give Acute Inferior-Lateral M.I. In A Patient With A Dominant Circumflex Artery 2/5</option><option value="60">Give Acute Inferior-Lateral M.I. In A Patient With A Dominant Circumflex Artery 3/5</option><option value="80">Give Acute Inferior-Lateral M.I. In A Patient With A Dominant Circumflex Artery 4/5</option><option value="100" selected="selected">Give Acute Inferior-Lateral M.I. In A Patient With A Dominant Circumflex Artery 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.5</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--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-hSUJLE9kJPAiRw8Bvjv3h-ydlrS4Rg8qoQ9ogvayqAU" /> <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/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item even"><a href="/ecg/inferior-lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-lateral M.I.</a></div><div class="field-item odd"><a href="/ecg/circumflex-artery" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Circumflex artery</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%2Facute-inferior-lateral-mi-patient-dominant-circumflex-artery&amp;title=Acute%20Inferior-Lateral%20M.I.%20In%20A%20Patient%20With%20A%20Dominant%20Circumflex%20Artery"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 31 Oct 2015 04:59:00 +0000 Dawn 673 at https://www.ecgguru.com https://www.ecgguru.com/ecg/acute-inferior-lateral-mi-patient-dominant-circumflex-artery#comments Inferior-Lateral M.I. https://www.ecgguru.com/ecg/inferior-lateral-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/inferior-lateral-mi-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW102%2012%20Lead.jpg" width="1800" height="708" alt="" /></a></div><div class="field-item odd"><a href="/ecg/inferior-lateral-mi-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW102%20Rhythm%20Strip.jpg" width="1800" height="676" 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 style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">This ECG and rhythm strip are from a 78 year old man with chest pain, but we have no other clinical data. This is a good example of inferior and&nbsp;low lateral injury, demonstrating the large amount of heart muscle that can be damaged when a dominant RCA or&nbsp;circumflex artery is occluded.&nbsp; The low lateral wall is often included in an inferior wall M.I. when the RCA wraps around the left side of the heart, or the circumflex perfuses the posterior descendng artery and the inferior wall.</p><p style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">In this ECG, we see a sinus rhythm with obvious ST segment elevation in Leads II, III, and aVF, with reciprocal ST depression n Lead aVL. &nbsp;There is reciprocal ST depression in V1 and V2, indicating that the inferior wall injury extends up the posterior wall until it is seen by the anterior leads V1 and V2 as ST depression. The term "posterior wall" has come into some scrutiny recently, but it is still commonly used, so we use it here.&nbsp;<span style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">There is also ST elevation in Leads V4, V5, and V6, reflecting the low lateral wall. &nbsp;</span></p><p style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;"><span style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">This is a great example of how the SHAPE of the ST segment is often altered in acute M.I. as well. &nbsp; Leads II, V4, V5, and V6 have obvious "flattening" of the ST segment. Even when the ST elevation is minimal, this shape is a STRONG indicator of M.I. &nbsp;Lead III has a convex-upward shape, another giveaway for an M.I. diagnosis.</span></p><p style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;"><span style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">Adding to the evidence for a diagnosis of acute M.I. are the associated signs: &nbsp;T wave inversion in Lead III (a sign of ischemia), and poor R wave progression in V3 through V6. &nbsp;Since V3, V4, V5, and V6 should all have strong R waves, this could be an ominous sign of impending pathological Q waves, a sign of myocardial necrosis. &nbsp;&nbsp;</span></p><p style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;"><span style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">The rhythm strips in this case demonstrate ST elevation also. &nbsp;There is artifact in Leads II and aVF. &nbsp; This example can be used for beginners who are learning lead concepts. &nbsp;Ask, "Which limb is the artifact coming from?" &nbsp;The answer is the right arm, because Lead III doesn't use the right arm, and it is clear of artifact.&nbsp;</span></p><p style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;"><span style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">An "editorial" comment here: &nbsp;If you are running a two- or three-channel rhythm strip, don't monitor Leads II, III, and aVF. &nbsp;They all show the inferior wall. &nbsp;In fact, aVF is a "hybrid" of leads II and III! &nbsp;It is not possible to calculate the frontal plane axis accurately with these three leads only. &nbsp;If you only have limb leads to choose from, choose I, II, and III. &nbsp;If you can add V1, it is a big plus.&nbsp;</span></p><p style="font-size: 13.0080003738403px; line-height: 20.0063037872314px;">&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/553/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 Inferior-Lateral M.I. 1/5</option><option value="40">Give Inferior-Lateral M.I. 2/5</option><option value="60">Give Inferior-Lateral M.I. 3/5</option><option value="80">Give Inferior-Lateral M.I. 4/5</option><option value="100" selected="selected">Give Inferior-Lateral M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >5</span></span> <span class="total-votes">(<span >4</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-2vyf92tHs0z3XqVUqos2EbgTQxN4n0hOLjOJv12OdCE" /> <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/inferior-lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-lateral M.I.</a></div><div class="field-item even"><a href="/ecg/myocardial-infarction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Myocardial infarction</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_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-lateral-mi-0&amp;title=Inferior-Lateral%20M.I.%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, 30 Mar 2015 03:41:42 +0000 Dawn 631 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-lateral-mi-0#comments Inferior-lateral and Posterior Wall M.I. https://www.ecgguru.com/ecg/inferior-lateral-and-posterior-wall-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-lateral-and-posterior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW100.jpg" width="1800" height="917" 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><span style="font-size: 13.3333339691162px; line-height: 20.0063056945801px;">This is from a Cardiac Alert patient, with chest pain,&nbsp;in the Emergency Department.&nbsp; The ECG shows ST elevation in the inferior leads (II, III, and aVF), and in the low lateral leads (V5 and V6). &nbsp;There is reciprocal depression in V1 and V2, indicating injury in the posterior wall. &nbsp;One could argue that "inferior" is just the term we use for the lower part of the posterior wall - the part that faces the floor in a standing person. &nbsp;So, "inferior-posterior" reflects a more proximal occlusion of the culprit artery.</span></p><p><span style="font-size: 13.3333339691162px; line-height: 20.0063056945801px;">The high lateral wall is represented by I and aVL. &nbsp;These leads would usually show marked reciprocal ST depression when II, III, and aVF have elevation. &nbsp;However, in this ECG, aVL is depressed, but not as much as expected, and Lead I almost looks elevated! &nbsp;This could represent even more extensive lateral wall involvement. &nbsp;A dominant right coronary artery could be the culprit, but it seems more likely that a dominant circumflex artery is to blame, as it could perfuse the entire lateral wall before joining with the posterior descending artery and perfusing the inferior wall. &nbsp;Unfortunately, we do not have the cath results on this patient.</span></p><p><span style="font-size: 13.3333339691162px; line-height: 20.0063056945801px;">The ST elevation in this ECG has the classic appearance of acute M.I., and will be interesting to both beginner and advanced students.</span></p><p><span style="font-size: 13.3333339691162px; line-height: 20.0063056945801px;">Often, one ECG can provide a wealth of teaching opportunities, no matter what the level of your students.&nbsp; For the student learning to monitor the rate and rhythm, you might crop this image to only show the Lead II rhythm strip at the bottom, for a good example of normal sinus rhythm with a borderline PRI of .20 sec.&nbsp;&nbsp; For the student learning about ST elevation M.I., this is a good example of inferior-posterior and lateral injury. &nbsp;Leads aVL, V1 and V2 demonstrate reciprocal ST depression.&nbsp; When an observant student notices the slight ST elevation in V6, a discussion of coronary artery distribution can occur. &nbsp;</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/553/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-lateral and Posterior Wall M.I. 1/5</option><option value="40">Give Inferior-lateral and Posterior Wall M.I. 2/5</option><option value="60">Give Inferior-lateral and Posterior Wall M.I. 3/5</option><option value="80" selected="selected">Give Inferior-lateral and Posterior Wall M.I. 4/5</option><option value="100">Give Inferior-lateral and 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 >3.6</span></span> <span class="total-votes">(<span >5</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-w4VQPC7z-KOkJ_LZB3u9WUxQC9smF1kXTQpu3IxBjS4" /> <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-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall 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/inferior-lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-lateral M.I.</a></div><div class="field-item odd"><a href="/ecg/inferoposterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferoposterior M.I.</a></div><div class="field-item even"><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 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_5"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-lateral-and-posterior-wall-mi&amp;title=Inferior-lateral%20and%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> Fri, 16 Jan 2015 05:55:02 +0000 Dawn 614 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-lateral-and-posterior-wall-mi#comments