29 year old, healthy, with pleuritic chest pain

A 29 year old male presented with 6 hours of stuttering chest pain, constant for the last hour, worse with breathing.  He had no medical history.

 What is the diagnosis?






Diagnosis:

There are Q-waves, ST elevation, and hyperacute T-waves in V2 and V3, diagnostic of acute LAD occlusion (STEMI).

Take home point here:

Obtain an ECG on anyone with chest pain. Sometimes you will find an obvious STEMI.

Clinical Course:

He was taken for immediate PCI of a 100% LAD occlusion with thrombus; door to balloon time was less than 60 minutes and symptom onset to balloon time was approximately 2 hours.

Nevertheless, he suffered a large infarction with peak troponin of 110 and the following ECG the next AM:

There are now deep QS-waves, with persistent ST elevation in precordial leads.  The shallow T-wave inversion is typical of completed transmural infarction, and contrasts with the deep T-wave inversion seen with quick reperfusion of an MI with much remaining viable myocardium.

He did not regain his R-waves after reperfusion.  Whether he will do so over the next months or not is uncertain now.   He has persistent ST elevation.  This may resolve over a couple weeks; if it does not, then he is at high risk of developing an LV aneurysm, or diastolic dysfunction of the anterior wall.  He is also at risk of a mural thrombus.

Q-waves in acute MI:

1) QR-waves are common early in anterior MI.
2) QS-waves are uncommon early in anterior MI; they are common in late presentation.
3) Q-waves are independently associated with worse outcomes (78% relative increase in 90-day mortality in Armstrong et al.)
4) Q-waves alone do not necessarily imply irreversibly infarcted myocardium; they should not dissuade from reperfusion therapy.

References:

Armstrong PW et al.  Baseline Q-wave surpasses time from symptom onset as a prognostic marker in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention.  J Am Coll Cardiol 2009;53(17):1503-9.

Raitt MH et al.  Appearance of abnormal Q-waves early in the course of acute myocardial infarction: implications for efficacy of thrmoblytic therapy.  J Am Coll Cardiol 1995;25(5):1084-8.