Thursday, March 3, 2016

Chest pain in an Elderly Woman

This case was sent by one of our great FOAM colleagues, Salim Rezaie of REBEL EM!!

"A 67 y/o female with PMH of Type 2 DM, HTN, Hyperlipidemia, and Hx of MI x 2, with chronic kidney disease awoke at 2am with left sided chest pain. She arrived at 2:45 AM and had this initial ECG below:"
What do you think? 

Smith response: 

There is sinus rhythm.  There is No significant ST elevation in any lead.   There are large, symmetric T-waves in I, aVL, V2-V5 diagnostic of proximal LAD occlusion.  There are also down-up T-waves in III and aVF (these are very specific RECIPROCAL findings and clinch the diagnosis.)

Salim was very worried about these T-waves and so brought the patient the Medical Resus room and did an immediate bedside echo (not shown) which he read as a lateral wall motion abnormality; then he activated the cath lab.

He recorded a second ECG 5 minutes after the first:
Now there is obvious high lateral ST elevation, as well as STE in V2, V3, V4, V5.

He writes:
"Patient was immediately taken to cath lab. Initial Troponin was <0 .03="" div="" ml.="" nbsp="" ng="">
(I'm not sure if 0.03 is level of detection or 99% reference, and I did not clarify that with Salim).

"We obtained that result after the patient was already gone. Subsequent Troponin I values were 53.6 ng/mL and 152.04 ng/mL."  This is a large anterior MI.

"In my mind this was a circ lesion due to STE elevation in lateral leads, but….

"Cath showed:

"Prox LAD 70% lesion
Large D1 100% occlusion
Distal LAD old 100% occlusion
Proximal Circ 20%
Prox RCA 50%"

"The reason I found this case interesting was two reasons:

"1. Initial ECG did not quite meet STEMI criteria, but obviously very concerning t waves and bedside echo findings.
"2. STE in 2nd ECG seen in lateral leads but also V2, V3, V4. Looks like reading in the literature you can have STE in aVL and V2 and this is commonly described with D1 lesions not circumflex lesions.

"Interested in your thoughts and if you think it is worthwhile for a Dr. Steve Smith blog post. Hope you are well."


My thoughts?: 
Great Case and Great job diagnosing this subtle LAD occlusion and getting her to the cath lab fast!

Culprit artery comment

STE in aVL and V2 does indeed often occur with a D1 lesion.  Some call it a "mid anterior MI".  In this case, though, as you say, the T-waves (EKG 1) and STE (EKG 2) were out to V5 and even V6, so this is the territory of a proximal LAD but still could be a D1 that serves a very large territory.

If there was thrombus, the proximal LAD 70% may have been occluded at the time of the EKG and this would account for all findings.  A co-culprit in D1 would not be terribly unusual.  

Circ lesions with STE in aVL: if they have any precordial finding, it is usually ST depression in V2 and V3 (simultaneous posterior MI), whereas D1 lesions look like this.

Overall Impression

The first ECG is immediately diagnostic to my eye, perhaps partly because the image from this case is burned into my retina:


  1. Just published a case report on ECG findings in acute first diagonal artery occlusions that reviews some of this literature.

    Durant E, Singh A, Acute first diagonal artery occlusion: a characteristic pattern of ST elevation in noncontiguous leads,
    Am J Emerg Med (2015),

  2. Thanks for the great case Dr. Rezaie and Dr. Smith. The first thing that caught my eye on the EKG was terminal QRS distortion in V3 on all 3 EKGs you have here, which alone would have had me very worried in the setting of chest pain. Is this correct?
    Great learning case and great clinical decision making!

    Dan Lee

    1. Dan,
      I thought you might see that. Excellent!
      Though I, too, saw this, I was slightly reluctant to mention it because it is important when the DDx is early repol vs. LAD occlusion. In this case, without any ST elevation at all, it is hardly early repol. Nevertheless, this absence of S-wave or J-wave is definitely abnormal.

  3. GREAT case Steve! Before looking at comments by you & Salim — my thoughts were that the very fat and disproportionately tall anterior T waves looked similar to what I’ve seen early on with DeWinter T wave tracings. Clearly we do not have the usual depressed J-point take-off, and T waves aren’t as tall as they are once DeWinter is fully developed — but early on DeWinter-type pattern may look like this esp. given: i) clearly abnormal (hyperacute) ST-T wave in aVL and I; and ii) reciprocal ( = mirror-image) ST-T depression in leads III and aVF — so my guess was impending proximal LAD occlusion based on the initial tracing. Against a circumflex lesion (in my opinion) is localization most of hyperacute changes in this tracing to the anterior leads. I especially think of lead aVL as more of an “anterior” rather than “lateral” lead — especially when I see similar changes occurring in other anterior leads … THANKS for posting! — :)

    1. Thanks, Ken! I totally agree:
      I believe de Winter's T -waves represent a condition of nearly, but not completely, obstructed flow. My guess is that, had we recorded this EKG 10 minutes earlier, de winters T waves would have manifested. After this time, the artery completely closed, and the EKG transitioned from de winters ST depression through isoelectric ST segments (The recorded EKG) to ST elevation. The first EKG is a snapshot of the time between ST depression and ST elevation. I did not write this on the post because it just seemed too complicated for most people.

  4. After having seen many your lessons on this blog, let me say that I have immediately got, if not the diagnosis, at least the fact that the first ECG is worrying. I have seen almost all ECG signs you mentioned.
    Dr. Smith, I thank you for your teaching and for your fantastic blog and clinical cases!


    1. Thanks for the feedback, Mario!

  5. As to de Winter, it seems that this ECG pattern is not so persistent as it appears according to the original paper of the Dutch group. What is your opinion? Many thanks.

    1. I think de winter's is dynamic and a transition, not stable. The publication implies otherwise, however.


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