A 16 yo Female with no previous medical history had a syncopal event while playing basketball. She arrived to the ED in
severe respiratory distress, awake but agitated. She was tachypneic in the 40s-50s. She was intubated
shortly after arrival, and had an ECG recorded:
 |
| Sinus tachycardia with massive ST elevation in I, aVL, V5 and V6, with extreme ST depression in V3 and V4, and reciprocal ST depression in II, III, aVF. This is diagnostic of a very acute posterolateral STEMI. |
The ECG was briefly inspected by a pediatric emergency physician unaccustomed to diagnosing acute MI. He did not recognize it and then set to the side. An emergency medicine ultrasound fellow came to ultrasound the heart and happened to glance at the ECG. He of course interpreted it as an acute STEMI although for a brief time this interpretation was doubted until the cardiac US showed a large wall motion abnormality.
The cath lab was activated. Pt was taken to the cath lab, arrested twice during catheterization, and was found to have a coronry occlusion related to an anomalous coronary artery. Unfortunately, the contributor could not remember the exact details of the cath nor of the specific intervention that was used to open the artery, but the patient did have ROSC, and eventual good neurologic outcome.
Lesson:
Children and young people do have MI. They may have premature atherosclerosis, Kawasaki disease coronary aneurysms, and anomalous coronary arteries. There are pediatric reports of MI due to LVH, cocaine, methamphetamine, and tumor embolism, dysplastic aortic valve They also have myocarditis, WPW, HOCM, long QT, congenital anatomic abnormalities and more. In trauma, they can have myocardial contusion.
When children have chest pain, syncope, dyspnea, or other potential cardiac symptom, record an ECG. It is cheap, noninvasive, and provides critical information.
Moreover, anyone with exertional syncope, at any age, needs a maximal stress test.
References
1. Excellent review article (unfortunately, no free pdf): Reich JD. Campbell R. Myocardial Infarction in Children. Am J Em Med 16(3):296; May 1998. http://www.sciencedirect.com/science/article/pii/S0735675798901073
2. Anomalous left coronary artery origin from the main pulmonary artery is the most common significant coronary artery anomaly (Bland-White-Garland syndrome).
Arciniegas E, Farooki ZQ, Hakimi M, Green EW. Management of anomalous left coronary artery from the pulmonary artery. Circulation. 1980;62(2 pt 2):I180–I189
Great case Dr Smith !!! I would never thought STEMI would happen in a 16 yo !!
ReplyDeleteOn a side note, is this a sinus rhythm or an atrial flutter? ( just my curiosity ) V1 shows flutter waves but the other leads dont; or the 'flutter waves' in V1 are just PR intervals?
It's a good question, but I marched it out and there is not the same interval between what appear to be flutter waves, so I am pretty sure it is sinus.
DeleteIf a woman can have a STEMI @ 16 years of age, then a woman can also have an NSTEMI @ 25: http://eurheartj.oxfordjournals.org/content/27/23/2745.long
ReplyDeleteThere are many (rare) possibilities such as vasculitis, dissection, thrombotic occlusion and anomalies (as in the present case)!
Great case Dr. Smith..thank you very much.
ReplyDeleteThanks, Mohammed!
DeleteShould these kids be getting the same adult intervention pre-hospital then?
ReplyDeleteWith the hindsight of an Echo and angiography it's easy to say 'yes'.
Not everyone is going to have the depth of knowledge or insight to consider managing their patient as a STEMI
This ECG is diagnostic of STEMI no matter how old or what the symptoms. Prehospital interventions are aspirin (yes), NTG (yes) and management of cardiac arrest should it happen. So there should be no difference in management, right?
DeleteI had a 17 year old male patient who threw a clot post surgery, and he was having a global STEMI. We treated him as we would any patient. Nitro, morphine, ASA, and transported emergency.
Deletethank you for this great case, we should think to MI even in very young people, i wonder if you have the posterior leads V7 V8 V9 to better visualize the posterior involvement.
ReplyDeleteUnfortunately not.
DeleteGreat case. Fortunately a good result despite some stutters early on in management. Important to remember that anomalous coronary arteries are among the most common causes of sudden death in a young population (after hypertrophic cardiomyopathy). THANKS for presenting.
ReplyDeleteP.S. Agree with you that this is not AFlutter - even though it initially looks like it might be. I had to print out the tracing and march it through with calipers before arriving at the same conclusion as you - that setting the calipers to precisely twice the R-R interval just doesn't march out (as it should if this was AFlutter).
I would call this a lateral or "high lateral" MI; there are no reciprocal ST depressions in the right precordium and the major ST elevations are in 1 and aVL with reciprocal depression only in the inferior leads 23F. Several years ago I was an expert in a legal case involving sudden death in a 16 YO female basketball player with exertional syncope that was not investigated. I would add to the recommendations that exertional syncope (syncope occurring during exercise, not postexertional orthostatic symptoms) merits evaluation including high-level or maximal treadmill exercise testing with physician in attendance and/or if the resting EKG or exam is abnormal, an echocardiogram. Exertional syncope is trouble.
ReplyDeletePlease remember to look at the lipid levels in anyone with an acute MI, even if, as in this case, an anatomic explanation is present! As noted above, young people CAN present with atherosclerosis and all too often cholesterol levels are not measured, or if measured are not noted to be elevated. Anyone with severe hypercholesterolemia (total cholesterol over about 300 mg/dL) should be referred to a lipidologist, A geographic listing of lipid specialists is available at lipid.org.
ReplyDeleteApart from mi the qrs is very wide and there are atrial flutter2:1 so she should be suspected of wpw.what about a lbbb can we suspect in this ecg.
ReplyDeleteIt is sinus. The QRS only appears wide because the ST segments are so elevated (and depressed). It is sinus with a normal QRS duration
ReplyDeleteImpresive !
ReplyDeleteI have to admit I wouldn't have thought a STEMI looking at that. More LBBB as has all the hallmarks in all the lateral leads & if that's the case then no further interpritation is possible & needs to be treated as acute LBBB.
ReplyDeleteAndrew,
DeleteFirst, it is not LBBB. what appears to be wide QRS is ST segment with a J-point that starts at the height of the R-wave. Look at lead II and you will see it can't be LBBB. Second, even if it were LBBB, there are multiple leads with concordant ST elevation, and many millimeters of it, so it is very Sgarbossa positive and diagnostic of STEMI.
Your statement that "no further interpretation is possible" in LBBB is very out of date. See this paper by me:
http://www.annemergmed.com/article/S0196-0644(12)01368-6/pdf
Any way you look at this, it is STEMI.
Steve Smith
I hv seen a patient of age 30 diagnosed case of Tuberculosis with no risk factors for atherosclerosis presented with MI.It was later assumed that he must have Coronitis secondary to Tuberculosis endartritis obliterans
ReplyDeleteexcellent teaching as always steve
ReplyDelete