Sunday, August 21, 2016

A 25 year old with Epigastric Discomfort, Worse Supine, Better Sitting Up.

This is another case provided by Mustafa Alwan, an internist from Jordan, on Facebook EKG Club  

This is a 25 year old male diabetic who presented with epigastric heaviness for 12 hours.  The discomfort was intermittent and associated with sweating and dizziness; it was increased increased by lying flat and relieved when sitting up.

Here is his initial ECG, with pain and diaphoresis:

It is really quite normal.
When I first saw it, I did not know the patient still had pain, and I responded on FB:

"This is normal.  However, the sharp downturn of the T-wave in V4-V5 suggests possible development of Wellens' waves, but is nonspecific. The T-wave flattening in limb leads is non specific."
However, with ongoing pain, these are unlikely to be vestigial Wellens' waves.

He was given NTG and Morphine and pain was improved.

An interventionalist was consulted.  
He performed an echocardiogram which showed no wall motion abnormality.  

The first Troponin T returned at 0.017 ng/mL, slightly elevated but indeterminate.  

The interventionalist diagnosed pericarditis and prescribed an NSAID.

[This ECG shows no evidence of either pericarditis or of STEMI.  The diagnosis must have been based on the positional nature of the pain.]

Dr. Alwan smartly recorded more ECGs.   Here is the second one recorded 4 hours later:
No significant change

6 hours after the first ECG, and 2 hours after the 2nd, a third ECG was recorded:
Now there is new ST elevation, the change being diagnostic of LAD occlusion.
This is not an ECG one would see with pericarditis, which manifest inferolateral ST elevation.

Even if this were the first and only ECG, the differential diagnosis would be early repol vs. LAD occlusion, and the formula could be used:

STE60V3 = 2.5 mm
 computerized QTc = 437
(notice how it lengthened from the earlier values of 372 and 402 ms!)
R-wave amplitude V4 = 9 mm
formula = 25.839 (greater than 23.4 is all but diagnostic of LAD occlusion)

The patient was taken for angiogram.  Here is the report:

Here is the post reperfusion ECG
Typical reperfusion T-waves, identical to Wellen's waves (Wellens' waves represent reperfusion!)

Learning Points:

1.  Young People can have myocardial infarction
2.  Though positional pain lowers the likelihood that chest pain is MI, it does not eliminate it!
3.  Always get serial ECGs.
4.  Pay attention to even slightly elevated troponin levels.  This could have been myocarditis, but that is a diagnosis of exclusion, after a negative angiogram.


  1. This is also an important illustration of loss of T wave balance T wave in V1 too tall vs V6 that is often missed. You, Amal Mattu and others have illustrated this point. and Marriott wrote about this many years ago
    Manno, et al - upright TV1 is common in patients with significant
    atherosclerotic disease of the left circumflex artery and right coronary
    + Marriott - if the TV1 is larger than the TV6, suspect anterior and/or
    lateral myocardial disease (chronic or acute)
    - May be an early marker of impending MI
    - A new upright tall TVi (NTTVi) may be a marker of acute cardiac ischemia
    + Chung - upright TVi suggests acute cardiac ischemia
    + Smith - TVi > TVe suggests acute cardiac ischemia
    + Barthwal - TVi > TVs is associated with ischemic heart disease
    - 84% specific for ischemic heart disease
    - 16% false positives
    - The NTTVi may precede other expected ECG changes in acute ischemia
    - Be especially concerned when the upright TVi is new and large
    [Amal Mattu, ACEP 2008]
    I find that this is an often missed finding.

    1. We did not find much of a difference in this between patients with early repol and those with subtle LAD occlusion. It did not add anything to our formula model because its discriminatory power is low and is a covariate with other variables.


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