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Instructors' Collection: Acute Anterior-lateral STEMI

The Patient:  A 60-year-old man at work. He experienced a sudden onset of substernal chest pain, nausea & vomiting, and dizziness.  He states the pain is a 5 on 1-10 scale.  No cardiac history or current medications. 

The ECGs:  The first ECG, 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.

There is obvious ST elevation in V1 through V5, which is the anterior wall, an area perfused by the left anterior descending artery.  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 only the sinus beats for ST changes. 

There is also obvious ST elevation in Leads I and aVL.  This is the high lateral wall, which is perfused by the circumflex and first diagonal arteries, both proximal branches of the left coronary artery.  So, the involvement of the high lateral wall indicates a proximal lesion in the LCA – not good.  Leads III and aVF have distinct ST depression – this is a reciprocal change reflecting the ST elevation in Leads I and aVL.

Dr A Röschl's picture

An Interesting Holter Strip

Here you can see a long rhythm strip from a Holter ECG, written at 25 mm/s. On the left, a sinus bradyarrhythmia can be seen first, followed by an atrial tachycardia. After a few beats this changes back into a sinus bradyarrhythmia. Then follows a short VT over 3 beats, after 1 sinus node beat then a ventricular couplet. Sinus bradyarrhythmia again at the end.

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Atrial Fibrillation With Rate-related Left Bundle Branch Block

For a better overview, the leads aVL and V2-V4 are not shown in this ECG. The basic rhythm is atrial fibrillation (no P waves or flutter waves visible, but fibrillation waves). When the conduction rate drops, the QRS complexes are narrow. Faster conduction results in wide QRS complexes with LBBB morphology. This is an example of phase 3 (acceleration dependant) LBBB.

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New Book From Dr. Jerry Jones

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Pacemaker leads: Atrial and Bi-ventricular

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Pacemaker leads

This original artwork was created by Dawn Altman.  It is free for your use in a non-commercial setting.  For commercial use, contact the artist at [email protected]. All rights reserved. (c) 2023

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ECG Glossary from Dr. Ken Grauer

Are you looking for a comprehensive ECG glossary that goes beyond simply defining words? Dr. Ken Grauer, who is the ECG Guru's Consulting Expert, has a Glossary available on his website that explains the terms.  Instructors and students alike will benefit from having this glossary readily available.  The glossary is exerpted from his e-Publication, "A 1st Book On ECGs - 2014", available on Amazon.

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ECG HISTORY:     ECG was first put into clinical use in the early 1900s.  In 1909, it helped diagnose an arrhythmia.  A year later, indications of a heart attack were noted.

 

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