Friday, November 11, 2011

Hyperacute T-waves, with a Twist

A 30 year old male complained of chest pain and then collapsed.  He was resuscitated from ventricular fibrillation.  He arrived at 0700.

These two ECGs were recorded at 17 minutes apart.

Which was first?

There are hyperacute T-waves in V1-V5, with some depressed ST takeoff in V3-V5.  There are also hyperacute T's in II, III, and aVF

There is ST elevation (injury) in V2-V4and II, III, aVF

The bottom one was recorded first, at 0719, the top one was recorded second at 0736.  The patient's artery had reperfused between the first and the second.

This illustrates nicely how hyperacute T-waves are present not only shortly after occlusion, but also shortly after spontaneous reperfusion, or, as I sometimes say: "both as the ST segments are on the way up, and on the way down."

As it turns out, the artery reoccluded, and at 0801, the angiogram showed a 100% occluded type III ["wraparound" (to the inferior wall)]  mid (after the second diagnoal) left anterior descending artery.  A large  thrombus was aspirated and the LAD was stented.

The EF later that day was 25%, with both inferior and anterior wall motion abnormalities.  However, as expected from the short duration of complete occlusion, the troponin I peaked at only 20 ng/ml.   A second Echo was done 4 days later:  the stunned myocardium had recovered, and the EF was 65%.

He underwent therapeutic hypothermia and in spite of some initial hypoxic encephalopathy, he completely recovered.

Click here to see the most popular post of all time, on hyperacute T-waves.

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