This is the ECG of a 50 yo old woman who collapsed, was found to have a pulse, but then found to be in ventricular tachycardia. She was shocked into sinus rhythm. She presented to the ED comatose.
There is marked ST elevation especially in leads V3 to V6, as will as limb leads I and II, with no reciprocal ST depression. The cath lab was activated for STEMI, but the patient had clean coronaries. Before initiating therapeutic hypothermia, a head CT was done and showed fatal subarachnoid hemorrhage.Case 2.
There is ST elevation in V1-V3 with hyperacute T-waves and Q-waves in V2 and V3. This is highly suspicious for acute anterior STEMI. However, she was found to have a fatal pontine hemorrhage and had a maximum troponin I, at 12 hours after presentation, of 2.0 ng/ml. Echocardiogram showed an anteroapical wall motion abnormality. In this case, since no angiogram was done, it is not proven that she did not have a simultaneous anterior STEMI, but with a low maximum troponin and alternative explanation, it is highly unlikely..
These cases demonstrate that SCM can present with STEMI pseudoinfarction patterns.
In Case #1 the widespread elevation and potential PR elevation in aVR had me consider pericarditis (especially given the tachycardia). Granted, the ST segments don't look like those in pericarditis.
ReplyDeleteIf there wasn't elevation in II I likely would not have considered pericarditis. Is the STE in II because of the extent of the SCM?
Indeed, I almost mentioned the similarities to pericarditis, which include inferolateral ST Elevation, STE greater in II than III, and absence of any reciprocal ST depression anywhere. Good point!
ReplyDeleteIn case one, you mention that there is no reciprocal depression, however had I seen this patient, I most likely would have been inclined to consider the ST-depression in aVR and V1 as reciprocal signs of a STEMI. What's your take on this, and am I missing something? Thanks for the fascinating cases and and clarifying my interpretation.
ReplyDeleteV1 may have minimal ST depression, but mostly it is baseline wander. As for aVR, it is always opposite the other leads and therefore any ST depression in aVR does not count as reciprocal. only the opposite of aVR (-)aVR is considered a consecutive lead: aVL, I, (-)aVR, II, aVF, III are consecutive.
ReplyDeleteIt is impossible to determine Takosubo's from the ECG. Really the diagnosis is made from shooting an angiogram of the ventricle in the absence if coronary artery disease.
ReplyDeleteThat is correct that it is not always possible to determine Takotsubo from the ECG. It is not, however, always necessary to do an angiogram. The clinical context (e.g., in these cases, intracranial bleeding) along with a cardiac ultrasound that shows apical ballooning, is sufficient. In addition, the minority of patients with Takotsubo have an ECG identical to STEMI. Some do.
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