A male in his 30s presented with chest pain, cough, and sore throat.
He had been seen in clinic the day prior for cough x 1 month and sore throat. A strep test was positive and he was treated with penicillin, and also with acetaminophen and ibuprofen.
On the day of ED (ER) presentation, he presented with 5 hours of intermittent sudden onset left side chest pressure unrelieved by ibuprofen, with associated vomiting and SOB. There was some association with moving and palpation, but also some improvement with NTG. An ECG was obtained immediately:
I was highly suspicious of MI, so an ACS workup was initiated and we recorded a bedside echo (unavailable) which showed no inferior wall motion abnormality (or anywhere else). He was given aspirin and clopidogrel 600 mg. Because of the absence of wall motion abnormality, the patient's age, and the atypical pain, we decided to serially evaluate him and not activate the cath lab. A second ECG was recorded at 37 minutes.
Around this time, the initial troponin returned at 2.0 ng/ml. Because he had persistent chest pain and persistent ECG abnormalities, we activated the cath lab. He was taken and found to have open coronaries. The angiographer was concerned about inadequate opacification of the distal left main and proximal LAD, and did intravascular ultrasound. He confirmed a plaque with fissure in the distal left main coronary artery. There was no indication for stenting, but aggressive and prolonged antithrombotic and antiplatelet therapy (to "cool down" the fissured plaque) was instituted for this very high risk lesion.
Here is the ECG after the cath:
Some have asked what I mean by deformed T-wave in V2. Here are V2 and V3 from the first 3 ECGs side-by-side:
Troponin I peaked at 8 ng/ml. A formal echo showed no wall motion abnormality. An ECG at 24 hours was recorded:
At 48 hours:
The troponins trended down from a peak of 8 ng/ml.
The ECG suggests inferolateral MI. The T-wave in V2 suggests either posterior or anterior ischemia. The angiogram is consistent with anterior (LAD) and posterolateral MI (left main supplies the LAD and circumflex), and of inferior MI if the the circumflex is dominant (the cath report did not specify this).
In any case, what would be considered by most to be a "nonspecific" ECG was highly suspicious and prompted rapid evaluation and management in a young man who might otherwise be thought "low risk" with young age and atypical chest pain. The finding of reciprocal ST depression in lead aVL confirmed the pathologic nature of the inferior ST elevation.
He had been seen in clinic the day prior for cough x 1 month and sore throat. A strep test was positive and he was treated with penicillin, and also with acetaminophen and ibuprofen.
On the day of ED (ER) presentation, he presented with 5 hours of intermittent sudden onset left side chest pressure unrelieved by ibuprofen, with associated vomiting and SOB. There was some association with moving and palpation, but also some improvement with NTG. An ECG was obtained immediately:
I was highly suspicious of MI, so an ACS workup was initiated and we recorded a bedside echo (unavailable) which showed no inferior wall motion abnormality (or anywhere else). He was given aspirin and clopidogrel 600 mg. Because of the absence of wall motion abnormality, the patient's age, and the atypical pain, we decided to serially evaluate him and not activate the cath lab. A second ECG was recorded at 37 minutes.
This is identical, except the terminal T-wave inversion in III is gone. |
Here is a magnification of lead III, for comparison:
Around this time, the initial troponin returned at 2.0 ng/ml. Because he had persistent chest pain and persistent ECG abnormalities, we activated the cath lab. He was taken and found to have open coronaries. The angiographer was concerned about inadequate opacification of the distal left main and proximal LAD, and did intravascular ultrasound. He confirmed a plaque with fissure in the distal left main coronary artery. There was no indication for stenting, but aggressive and prolonged antithrombotic and antiplatelet therapy (to "cool down" the fissured plaque) was instituted for this very high risk lesion.
Here is the ECG after the cath:
The STE and reciprocal ST depression are gone, and T-waves are smaller. The previously deformed T-wave in V2 is normal now. |
Some have asked what I mean by deformed T-wave in V2. Here are V2 and V3 from the first 3 ECGs side-by-side:
Troponin I peaked at 8 ng/ml. A formal echo showed no wall motion abnormality. An ECG at 24 hours was recorded:
This confirms inferior and lateral infarction, with increased ST elevation and evolution of T-waves (reperfusion T-waves). |
At 48 hours:
Further evolution |
The troponins trended down from a peak of 8 ng/ml.
The ECG suggests inferolateral MI. The T-wave in V2 suggests either posterior or anterior ischemia. The angiogram is consistent with anterior (LAD) and posterolateral MI (left main supplies the LAD and circumflex), and of inferior MI if the the circumflex is dominant (the cath report did not specify this).
In any case, what would be considered by most to be a "nonspecific" ECG was highly suspicious and prompted rapid evaluation and management in a young man who might otherwise be thought "low risk" with young age and atypical chest pain. The finding of reciprocal ST depression in lead aVL confirmed the pathologic nature of the inferior ST elevation.
Dr. Smith,
ReplyDeleteregarding the evolved T wave in V2...
I believe it could suggest posterior ischemia because the much larger upright T wave may be the reciprocal of a posterior reperfusion T wave if I am following you correctly.
How, though, might it represent "anterior ischemia"?
-David
It is the deformation of the T-wave which could be anterior ischemia, and then it normalizes. I don't see a lot of evidence of a posterior reperfusion T-wave (it is not abnormally large), but it could be. I don't think we know enough about T-wave dynamics in LAD ischemia, but there given the cath results, LAD ischemia at the time of the ECG was highly likely.
DeleteDefinitely, should have mentioned it and will edit it. Thanks.
DeleteHi,
ReplyDeleteYou mention the other large T waves, but what about in lead aVF - it is not huge in absolute terms, but towers over the QRS complex. Would you go by this as well? It stood out to me, moreso than the others. Thanks,
Eric
Dr. Smith,
ReplyDeleteGreat case and good work.
If possible could you please elaborate a bit more on what is meant by the deformed T- wave in V2?
Thank you.
I will put a graphic in to show it
Delete