Dawn's picture

This week's ECG for your collection was kindly donated by Dr. Stasinos Theodorou, interventional cardiologist with the Limassol Cardiology Practice in Cyprus. It offers a wonderful teaching opportunity, and illustrates how valuable an ECG can be in locating a lesion during an M.I.   Dr. Theodorou previously posted this ECG and the angiograms from the same patient on FaceBook, and he has offered them to the users of the ECG Guru website  free of copyright.

Dr. Theodorou reports that the culprit lesion in this M.I. was initially very difficult to find on angiogram.  In this case the culprit was an ostially occluded second diagonal artery which, due to the anatomy, was almost impossible to spot from the initial diagnostic images.  There was no "stump" because the occlusion was in the ostium - the beginning of the artery.  The patient also had a significant right coronary artery lesion, but it was not the cause of the M.I. because the RCA perfuses the right ventricle and inferior/posterior wall of the left ventricle.  The ST elevation in this ECG is in I and aVL - the area of the high lateral wall.  Because the  ECG appeared to be inconsistent with the angiogram, Dr. Theodorou obtained further projections, allowing him to identify and treat the offending lesion.  This illustrates the importance of the ECG in locating coronary artery lesions, even in this age of high technology and cath labs.  The interventional cardiologist's proficiency in ECG interpretation enabled him to find this "invisible" lesion.

We are grateful to Dr. Theodorou for sharing this valuable learning experience with us.  You can find more from Dr. Theodorou on his website, FaceBook page, and here, on our "Ask the Expert" page.


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ekgpress@mac.com's picture

     Great teaching case — with our gratitude to Dr. Stasinos Theodorou for posting the ECG and cath films on the ECG Guru (and for allowing us copyright-free use of this material! ).

  • Dawn has described the case fully. The ECG shows sinus rhythm with marked ST elevation limited to leads I and aVL — with "mirror-image" ST depression in the inferior leads.
  • NOTE — there is also ST segment straightening in lead V2, with slight-but-real elevation of the J-point takeoff in this lead. This picture in lead V2 is all the more remarkable (assuming it is NOT due to lead misplacement — which I do not think is the case) — because ST elevation is ISOLATED in the precordial leads to V2. 
I review coronary anatomy and prediction of the likely "culprit artery" with acute LAD (Left Anterior Descending) occlusion in my ECG Blog #82. In ECG Blog #80 — I review acute RCA (Right Coronary Artery) occlusion.
  • PEARL: As I discuss in Blog 82 — ST elevation in lead aVL often provides a key clue to the location of the acutely occluded coronary artery. As described in a study by Birnbaum et al (Am Heart J 131:38, 1996) of a group of patients with ST elevation in lead aVL — when the ST levation was only in leads aVL and in V2 — but in no other precordial leads — this most often suggestsed acute occlusion of the 1st or 2nd Diagonal branch of the LAD. This is NOT a common lesion — but as per Dawn, in this case awareness of this pattern was invaluable for suggesting the anatomic lesion that initially was NOT evident on cath.
Great illustrative case — so THANK YOU Dr. Theodorou!

Ken Grauer, MD  www.kg-ekgpress.com   [email protected] 

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