Sunday, February 14, 2016

Is it early repol, pericarditis, or anterior STEMI?

This was sent to me by a reader:

This patient was a 26y/o pulled over by Police when he complained of chest pain that radiated to left arm. EMS was called. The initial 12 lead is here:

Smith comment:
There is sinus tachycardia.  There is a high voltage QRS, particularly high voltage S-waves in V2 and V3.  There is marked ST elevation in V3-V5, but there are also very marked J-waves in those leads and the T-waves are not large relative to the QRS.
This is all highly suspicious for early repolarization, especially in a 26 year old.
One can use the LAD occlusion vs. early repolarization formula: I have magnified V1-V6 for better measurement:
STE at 60 ms after the J-point in lead V3 (STE60V3) = 4 mm, QTc = 386 ms, and R-wave amplitude in V4 (RAV4) = 16 mm, we get 22.342


Interpretation:
A value of 22.342 strongly supports early repolarization (about 95% sensitive for LAD occlusion in all comers, but has a better negative predictive value in a 26 year old).

With this, I would do serial ECGs and an emergent echo to look for a wall motion abnormality.  I would not activate the cath lab, as LAD occlusion is very unlikely.  

Of course it is better to be safe than to miss an LAD occlusion, but a an echocardiogram done with contrast and interpreted by an expert will not miss an LAD occlusion and would spare the cath team a night time activation.


Outcome:
Crews became concerned about ACS and administered ASA, nitro, and serial ECG's showed no change in ECG.

The patient was taken to the cath lab upon arrival at hospital.

When I first saw this ECG I thought the elevation looked concerning but the QT was not that long and there is huge QRS in anterior and lateral leads. QRS in lead V4 is at least 15 according to my calculations give or take. I saw no reciprocal depression.


Pt went to the cath lab where his coronaries were found to be clean. Troponin's were not elevated. Cardio echo showed no wall motion abnormality and good function.  The patient was observed overnight and discharged the next day with diagnosis of pericarditis.

Comment:

I doubt this was pericarditis.  Pericarditis has inferolateral ST elevation primarily.  This is classic early repolarization.








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