Wednesday, September 2, 2015

A 21 year old with Chest pain

A 21 year old presented with typical chest pain.  Here is his ECG:
There is inferior and lateral ST elevation.  Pericarditis, right?

The key to this being STEMI is the ST depression in V2, and perhaps a touch in aVL.  This is very nearly a de Winter's T-wave.  ST depression is not seen in pericarditis, though it can be seen in myocarditis.  Due to this ST elevation, one must assume that this is ischemic ST elevation.

There is saddleback, but the saddleback is in V3 and V4, not V2.  More important is that there is ST depression, in which case saddleback morphology is NOT reassuring.

The emergency physician had to push for cath lab activation, but she was successful.

The LAD was full of thrombus and had aneurysms.

It was later found out that the patient had Kawasaki's disease in childhood (the cause of the coronary aneurysms, inside of which thrombus formed).

Learning Points:

1. Young people do have MI
          a. Some of these MIs in young people are due to anomolies: aneurysm from a disorder known to be associated  with coronary aneurysms (left out to maintain anonymity) in this case.  Young women, when they have STEMI, often have coronary dissection.
          b. Nevertheless, even young people have atherosclerosis and plaque rupture.  We have seen many, such as this young woman

2. You diagnose pericarditis at your (and your patient's) peril.  

3. Pericarditis should not be diagnosed if there is reciprocal ST depression anywhere.

Some other cases:

Here is a 16 yo girl with STEMI
Here is a young man with STEMI diagnosis missed
Here is a 24 year old woman with massive anterior-inferior-lateral MI that could be erroneously mistaken for pericarditis  (this is the one linked to above)


  1. isn't there a also a clear Q wave in V2-V4?

    1. Definitely, but I wanted to emphasize features which can only be acute.
      Steve Smith

  2. 1) STE inferior, lateral, ... de Winter anterior
    2) LAD thrombus
    3) perhaps wrap around ?
    4) angiogramm ?

    thanks de Smith


  3. That elevation looks really diffuse... May very well have fooled me. Could pericarditis with a misplaced v2 lead cause a similar appearance?

    1. I don't see how it would, but thanks for the comment.
      Steve Smith

  4. Does the occlusion here distal LAD OR proximal ?As proximal LAD occlusions often show reciprocal ST depression in the inferior leads , but when the LAD occlusion is more distal, you may not see any reciprocal inferior ST depression at all?

    1. Mid or proximal LAD with wraparound to inferior wall. If proximal, simultaneous ischemia of high lateral wall and inferior wall cancel each other out, so the aVL is isoelectric.

    2. Which lead affect more than other :aVL vs lead III? in case of high lateral and inferior infarction .
      i.e does STE in lead lead III affect STE in lead aVL ? and make it less elevated -isoelectric- (aVL)
      OR does STE in lead aVL affect lead III more and make it (lead III) less elevated ( isoelectric)
      Thanks with regards

    3. That depends o the axis of the ST elevation, whether more towards or away from aVL, or more towards or away from III. III and aVL are not exactly opposite, but 150 degrees opposite each other.


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