The Patient:67-year-old man complaining of chest pain radiating to his jaw, 10/10. He is short of breath and diaphoretic. We do not know his BP, just that it was low.The patient states “no past medical history – never hospitalized”. He thought himself to be very healthy.He was given aspirin 325 mg and transported to a full-service cardiac hospital as a “cardiac alert”.
The ECG (from EMS):
The rhythm is atrial fibrillation with a rapid ventricular response (about 134/min.). The QRS width is .118 seconds (118 ms).The frontal plane axis is slightly to the left, but WNL. The R wave progression mostly normal, but V4 is incongruous. V2 and V3 have a tall R wave, possibly representing a pathological Q on the posterior side.There are ST CHANGES in every lead. ST elevation is noted in III, aVF, aVR, V5 and V6, representing ischemia in the inferior wall. There is ST depression in all other leads, indicating widespread subendocardial ischemia and/or acute reciprocal depression.Interesting that Lead II would normally be elevated when III and aVF are, but aVR is elevated, causing reciprocal ST depression in Lead II.So, Lead II looks almost normal.
The pattern of ST elevation in aVR with widespread ST depression can indicate:
The Patient:This ECG was obtained from a man in his mid-sixties who was complaining of chest pain. The pain had an acute onset and is described as "10" on a 1-10 scale. He has a PMHx of coronary artery disease with stents in his right coronary artery and minimally invasive aortic valve replacement.
The ECG: The rate is 86 bpm. The rhythm is normal sinus rhythm with one PAC (10th beat). The PR interval is .18 seconds (176 ms), the QRS duration is .122 seconds (.12 seconds). This represents a ventricular conduction delay. There is no right or left bundle branch block. The QT/QTc is 333 ms/400 ms (B). The frontal plane QRS axis is leftward, with criteria for left anterior fascicular block. LAFB can be explained by this patient's history of prior CAD and valve replacement. There is ST elevation in Lead I and also in V1-V6. The ST segments have a straight shape in Leads I and aVL and in V1-V6. This shape represents ischemia in a patient with these symptoms and ECG findings. This is an ANTERIOR-LATERAL OCCLUSIVE M.I.
Followup: The patient was taken to the cath lab and had angioplasty of an occlusive mid-LAD (left anterior descending) lesion and a partially-occlusive mid-RCA lesion.
