Tuesday, January 12, 2010

Coronary occlusion need not have 1 mm ST elevation; often it does not

A 53 year old male with no previous cardiac history presented with sudden substernal chest pain with tingling of bilateral arms and dyspnea.

this is the first ECG at 1559:

There is very subtle and < 1 mm ST elevation in II, III, and aVF. The T-waves in these inferior leads are much larger than normal, with almost the same voltage as the QRS, and are "fat". These are hyperacute T waves. Just as importantly, there is minimal reciprocal ST depression in aVL, with T wave inversion. This is diagnostic for inferior STEMI, even though it doesn't meet the arbitrary criteria of 1 mm ST elevation in 2 consecutive leads. The cath lab was activated and a distal RCA thrombus with TIMI-0 flow was seen. For technical reasons, it could not be opened. An ECG was repeated, showing the development of the inferior MI without reperfusion:



  2. It has been really helpful.Should this patient be thrombolysed if facilties for cardiac intervention are not available ?

  3. I would, because I would be very sure of the diagnosis. But you must be certain of the diagnosis in order to give fibrinolytics. But if you're not certain, you can: get serial ECGs (they will evolve if it is early occlusion) and/or get an immediate echocardiogram.

  4. On the second ECG there is some ST depression in V1-V3 and a little bit of ST elevation in V5-V6. I guess it must have been a very big RCA.

  5. Yes, indeed. An infero-postero-lateral STEMI!


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