Sunday, June 16, 2013

37 yo with 1.5 hours of burning chest pain

A 37 year old with a history of DM on metformin complained of acute onset of burning chest pain.  He called 911. They did an ECG but it is not available.  However, the medics were very concerned and brought him to the critical care area with a high suspicion of STEMI.  Here is the initial ECG:

This shows sinus rhythm and abnormal septal Q-waves in V1 and V2, with what appear to be hyperacute T-waves in V2-V4.  The computer read ***Acute MI***.  Though the early repol vs. anterior STEMI formula, strictly speaking, should not be used because there are Q-waves, if you did, you would use STE60V3 = 3.5 mm, RAV4 = 8.5 mm, and computerized QTc = 413.  This gives a value of 25.8, indicating anterior STEMI.


So this ECG would seem to support anterior STEMI.  The cath lab was about to be activated.  However, there was a previous ECG from 3 months prior:

This is nearly identical, and establishes that the first ECG is not acute STEMI.

The patient ruled out for MI by serial troponins.

Is there an old MI present?  The best way to evaluate that would be an echocardiogram.  However, none was ever done. 

Whether this patient has coronary disease is unknown.  His ECG suggests it, but does not prove it. 

When the patient had presented the first time, he had chest pain, and they were unconcerned about the ECG and they got lucky as he simply ruled out by troponins.

Lesson:

Whenever the ECG is abnormal, look for a previous one before coming to conclusions!

10 comments:

  1. Very interesting baseline ECG! I think I would have activated from the field on that one, provided the right clinical context.

    Out of curiosity, do you know what his presenting complaint was with the baseline ECG?

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    1. Christopher,

      good question. It was chest pain. They never activated the cath lab then, even though at that time there was no old ECG. They got lucky because he ruled out.

      Steve

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  2. In addition to the Q-waves you mention, I would imagine the poor R-wave progression associated with LAFB would skew the results of your formula. There's criteria both for and against LAFB on these tracings, but I'm leaning towards it being present.

    Interesting case. Even with the old tracing the ST-segments on the current ECG look a bit more convex and would have me concerned. Thanks for posting!


    As one more aside, due to the multiple abnormalities on these tracings and I'm left wondering if the patient already has significant CAD or even a prior undiagnosed MI at his young age.

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    1. Vince,

      It would be an unusual LAFB given the S-waves in I and II (axis superior but slightly to the right).

      Really formula should only be used when the DDx is early repol vs. STEMI. This one does not look anything like early repol.

      Steve

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  3. Hi! Nice case, GREAT BLOG!
    What about the tall R wave in avR... Plus the changes in the anterior wall may indicate ventricular aneurysm! Explain the burning... But the cardiac markers would be elevated... Or not... maybe just the dimmers... What do you think?
    Sorry for my english...
    THANKS!! :)

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    1. Yes, the tall R-wave in aVR goes along with the S-waves in I and II, all together making for right axis deviation. But I don't see other criteria for, say, RV hypertrophy.

      As for LV aneurysm, it does not have a hyperacute looking T-wave like this, so unlikely.

      See my other posts on LV aneurysm (go to labels on sidebar)

      Steve Smith

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  4. Hi. it could be a Left Septal fascicular block where exist q waves in v1 and v2.

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    1. This comment has been removed by the author.

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    2. Diana,

      That is a very good idea, and you may be right.

      However, there are 2 complications with this:

      1) one should not diagnose anterior hemiblock when the S-wave in II is deeper than the S-wave in III:

      "As a general rule, whenever the S wave in lead II is deeper than in lead III, the diagnosis of LAH is quite unlikely; the VCG with characteristic counterclockwise rotation of the QRS loop in the frontal plane can always help the diagnosis.(1,2)"

      2) True left anterior hemiblock has a delay from onset of QRS to peak of R-wave in aVL of 45 ms. Here it is only 40 ms.

      Still, these are rather technical points and you may very well be right about it.

      This comes from this excellent article on hemiblocks:
      http://circ.ahajournals.org/content/115/9/1154.full.pdf+html

      Thanks so much for your insightful comment!!

      Steve Smith

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    3. Thanks for the article Dr Smith and for your answer. I´ll read the paper.

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