Tuesday, August 14, 2012

Reciprocal (Negative) Hyperacute T-waves. What is the Diagnosis?

I was shown this ECG and asked if I think it is a STEMI.  What do you think?

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I answered that it does not meet any criteria for STEMI, but that there are hyperacute reciprocal (negative) T-waves in I and aVL and this cannot be anything other than inferior STEMI, especially since the ST depression in V2-V5 suggests concomitant posterior STEMI.

The ECG findings resolved before cath.  At cath, there was an 80% hazy thrombotic lesion in the RCA.  Thus, this was indeed an acute RCA occlusion.  Echo the next day showed an inferior wall motion abnormality.

Lesson: Reciprocal ST-T changes are often more pronounced than the ST-T changes overlying the affected myocardium.  This is particularly common when there is lateral STEMI with inferior ST depression (see these two cases).

Here is a case in which there are both inferior and reciprocal hyperacute T-waves.


10 comments:

  1. Dr. Smith,

    I appears to me that lead III has a slight amount of convex ST elevation, perhaps 0.5mm, and lead aVF has an even slighter amount of ST elevation, but it does seem to be there. Do you agree with this?

    Dave B

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    1. Yes, but they are not particularly typical of MI, such that, without the reciprocal changes, I would not be highly suspicious of MI.

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  2. I realize this is not the main point of your post, but how eager are your cardiologists to take "resolved" ECGs to the cath lab?

    Thanks for your emphasis on aVL in RCA occlusions - it really helped with a recent patient!

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    1. Unequivocal STEMIs that resolve by the time they get to the ED, or in the ED, need to go. They are ready to close off at any moment. Our interventionalists realize this, especially because of one very bad case I had many years ago. Perhaps I'll post that case.

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  3. Is it enough to convince me to thrombolyse if PCA not available

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    1. I would do serial ECGs. In this case, it would have resolved. In cases of persistent occlusion, it will evolve. Then give thrombolytics. If it reperfuses, as here, and you don't have a cath lab, give ASA, clopidogrel, heparin, and a GP IIbIIIa inhibitor. Then transfer. OK?

      Steve Smith

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    2. Would a posterior ECG have given more concrete information to act upon? If thrombolysis was your only option.

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    3. Yes, that may have helped. Uncertain, of course. I think if the patient continued to have pain, serial ECGs would probably eventually turn unequivocally positive. But in order to do that, you have to have an elevated index of suspicion.

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  4. Steve, we know that the ST-segment depression does not give information about the localization of ischemia. In conducting the stress test ischemia detected in lead V5 in most cases. Does this mean that in the case such as this, the absence of ST depression in V5 speaks in favor of reciprocity of such a depression? In other words, reciprocal depression allows us to localize the coronary occlusion? I apologize for my English. Thanks.

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    1. I'm not entirely sure what you're asking, but I think it is this: even though ST depression does not localize subendocardial ischemia, does reciprocal ST depression localized STEMI? And the answer would be yes. Check out this post on ST depression: The 5 patterns of ST depression: http://hqmeded-ecg.blogspot.com/2012/02/five-primary-patterns-of-ischemic-st.html

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