Friday, October 9, 2015

Transient STEMI, no T-wave Evolution and no Wall Motion Abnormality

A Middle-Aged male had chest pain.  Here is his first ECG:
Obvious Anterior STEMI (note that among the findings is terminal QRS distortion (no S-wave or J-wave in V3)

No Echocardiogram was done at this point, but you can be certain that there was an anterior-apical wall motion abnormality (WMA) during this ECG.

Shortly thereafter, his pain resolved:
The STEMI is completely resolved.  Even the S-wave in V3, and the J-wave in V4, are restored.

A bedside echo was done and showed no wall motion abnormality.  Granted, this was not done with contrast or interpreted by a super expert, but an anterior STEMI should show some WMA.


The cath lab was activated and the patient went for PCI of a critical acute LAD stenosis with thrombosis.  There was TIMI-3 flow prior to the intervention.  A stent was placed.

This ECG was recorded after the procedure, 2.5 hours after the first ECG:
No significant change from the last one

A formal echocardiogram was done which was completely normal.

Serial troponin I peaked at around 1.2 ng/mL.

Another ECG was recorded about 10 hours after the first one.  
This is remarkable for no T-wave evolution.
Usually, when there is transient STEMI and positive (even though not very high) troponins, the ECG develops "reperfusion T-waves" or "Wellens' waves."

Usually, after transient STEMI, there is some residual wall motion abnormality for at least a day or so.

But not always!!!

Some argue that a normal echo in the course of an evaluation for MI means that no MI is ongoing.  But wall motion can recover extremely rapidly after spontaneous reperfusion.

Learning Point:

If the ECG findings have resolved, the wall motion may be recovered also

Question in my mind:

Does complete normalization of the ECG after reperfusion, with the absence of any T-wave evolution (reperfusion T-waves), predict full wall motion recovery?   I can find no literature on this, but I strongly suspect it is true. 

What is the clinical significance?

If the serial troponins are normal, as is often the case, and you do not record the ST elevation when it is there, you may entirely miss this case of ACS because there are no Wellens' waves and no wall motion abnormality.

The link below has some such cases:

See here for more cases and discussion of Transient STEMI, including literature.



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