Friday, December 13, 2013

A Male in his 60s with Chest pain. What is the ECG Diagnosis?

Here is the ECG of a man with 2 hours of chest pain.  He had a history of MI with LAD stent.  I cannot find his prehospital ECG, but the medics did not activate the cath lab.

Diagnosis?  See Below.

Inferior STEMI with hyperacute T-waves, trace ST elevation in inferior leads with reciprocal ST depression in aVL and reciprocal T-wave inversion in aVL.  The T-waves are massive in comparison to the QRS.  There is T-wave inversion in V2 that is highly suggestive of posterior MI as well.

This is diagnostic of inferior MI.  Nothing else does this.

The clinicians were uncertain, but they suspected MI. They did a right sided ECG which was not helpful.

They did another right sided ECG 32 minutes later.

In spite of absence of evolution on serial ECG, the cath lab was activated.

There was a 100% occlusion of the distal RCA. 


  1. Not to pass judgement on the providers involved (well maybe a little...), but I see a lot of folks running things like right-sided and posterior leads when it seems like they don't quite know what they're looking for or how to use the results. In this case, the fact that they chose to repeat the right-sided leads 30 min after their first set makes me think that might have been at play.

    It makes sense on a superficial level and shows they were rightly worried about an inferior MI, but I've never seen right-sided leads effectively pick-up a subtle STEMI that wasn't apparent on the standard 12-lead. Or am I just reading too much into the case and the choice of lead placement wasn't a little weird?

    1. Vince, I think you are almost completely correct. First, this ECG is absolutely diagnostic, and the only advantage to a right sided ECG is to see if the RV is involved and be prepared for the hemodynamic consquences. Most RV infarcts will show in V1, on the other hand. However, when the standard ECG is not positive, there are rare instances in which an isolated RV infarct can be diagnosed when there is a conclusion of the right ventricular marginal branch alone. I have a great example of this in my book. So it is not always futile to get a right-sided ECG when there is no inferior STEMI.

    2. Thanks, for the reply. As soon as I can pry my copy of your book away from Christopher Watford I'll be looking for that case. I was ecstatic that by blind luck I managed to pick one up on Amazon just before they disappeared a couple of years ago.

    3. Right now there are 3 used copies for sale on Amazon, 2 at $3000.00 and one at $13,000.00!!!

  2. After following your blog for a while I didn't hesitate for a second to call this an inferior MI. Thank you!

  3. I tell my student: in case of CP, eventhough in case of known coronary disease, always compare the repolarization volume vs depolarization volume. In this case, the QRS are pretty small, especially in aVF, and the T waves are HUGE = ischemia otherwise unproven!


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