What is the diagnosis?
There are Q-waves, ST elevation, and hyperacute T-waves in V2 and V3, diagnostic of acute LAD occlusion (STEMI).
Take home point here:
Obtain an ECG on anyone with chest pain. Sometimes you will find an obvious STEMI.
He was taken for immediate PCI of a 100% LAD occlusion with thrombus; door to balloon time was less than 60 minutes and symptom onset to balloon time was approximately 2 hours.
Nevertheless, he suffered a large infarction with peak troponin of 110 and the following ECG the next AM:
He did not regain his R-waves after reperfusion. Whether he will do so over the next months or not is uncertain now. He has persistent ST elevation. This may resolve over a couple weeks; if it does not, then he is at high risk of developing an LV aneurysm, or diastolic dysfunction of the anterior wall. He is also at risk of a mural thrombus.
Q-waves in acute MI:
1) QR-waves are common early in anterior MI.
2) QS-waves are uncommon early in anterior MI; they are common in late presentation.
3) Q-waves are independently associated with worse outcomes (78% relative increase in 90-day mortality in Armstrong et al.)
4) Q-waves alone do not necessarily imply irreversibly infarcted myocardium; they should not dissuade from reperfusion therapy.
Armstrong PW et al. Baseline Q-wave surpasses time from symptom onset as a prognostic marker in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. J Am Coll Cardiol 2009;53(17):1503-9.
Raitt MH et al. Appearance of abnormal Q-waves early in the course of acute myocardial infarction: implications for efficacy of thrmoblytic therapy. J Am Coll Cardiol 1995;25(5):1084-8.