Sunday, May 8, 2016

60-something with Chest Pain, resolved upon arrival to the ED

A 60-something male called 911 for chest pain of less than one hour duration.  He arrived in the ED pain free and had this ECG recorded:

What to you think?

There are hyperacute T-waves in V2-V4, but the patient was pain free.  I did wonder if he had had a prehospital ECG recorded, and what it showed.  

This was 10 years ago, just when we had started doing prehospital 12-lead ECGs.  I was not even certain that one had been recorded, but if it was, I wanted to see it.

I had to look around for it, and here is what I found:

Pretty amazing, huh?

Here I have circled the computer algorithm interpretation, just so you don't miss it:

Early Repolarization???
Notice STE is both precordial and in I/aVL.

He was taken to the cath lab and there was a fresh thrombus in the proximal LAD with 80% stenosis.  

Serial troponins were all undetectable (these are less sensitive than today, but as I pointed out in my last post, the initial troponin in STEMI, even with high sensitivity troponin, can be below the level of detection.

Here is another case where the physicians did not seek out the prehospital ECG and it led to loss of myocardium, but in this case for missing the evolution.  The initial troponin was below the level of detection.

Learning Points:

1.  In spontaneously reperfused "Transient STEMI," hyperacute T-waves may still be present after resolution of pain and resolution of ST segments.

I say: "you get hyperacute T-waves on the way up (as ST segments are on the way up, shortly after occlusion) and on the way down (after ST segments have normalized, shortly after reperfusion)

2.  The Initial troponin is often undetectable in STEMI

3.  Serial troponins may be all negative in transient STEMI

4.  Always look for and examine the prehospital ECG.


  1. Hello,
    would you expect reperfusion T waves (Wellens pattern) to form, following these on-the-way-down hyperacute T waves? Thanks, Stan.

    1. Yes, usually they would but almost always with a positive troponin. when troponin is negative, Wellens' waves may not form. In other words, Wellens' waves are a sign of myonecrosis (infarct).
      Steve Smith

  2. GREAT case Steve! I'd add to note the loss of anterior R wave in the current tracing (compared to the one from 10 years earlier) — so in a patient with new chest pain, this is new until proven otherwise. As you imply, "What goes up [ie, T waves] — must come down". Since we usually don't know how tall the T waves were before the ECG we are looking at — we have no way of knowing if what we are looking at is going up or down ... THANKS for posting. You may want to link your recent post of T hyperacute anterior T waves to this post (and vice versa).

    1. Thanks, Ken. Should have linked before I has so many hits. But I find that people rarely click on links in a post anyway.

  3. Thanks for the case

    In context of stemi
    1- The more deep the T wave the more viable myocardium

    2- The wellen is a sign of infract

    would you please explain more on these

    1. 1. That would be reperfused STEMI. In general, the size of a hyperacute T-wave correlates with amount of ischemic, but viable myocardium. Analogous, after reperfusion, the size of the inverted T-wave correlates with the amount of reperfused myocardium
      2. Wellens' is a sign of reperfusion of myocardium that was completely ischemic during pain but now is reperfused

    2. That was helpful

      Thanks :-)

  4. Great case! Just saw this exact phenomenon on a recent shift. T-wave inversion in aVR + hyperacute T-wave in II and III. Patient was pain free on arrival (got nitro on the way in) but a had a clammy handshake. The prehospital ECG showed an inferior STEMI.

  5. Dr Smith , thanks for your great blog and the time you invest in it.
    In regards to the morphology of the prehospital V2 and V3, is this what we would call anterior terminal QRS distortion - J point elevation > 50% QRS and lacking an S wave, being indicative of STEMI. Thanks Troy

    1. Troy,
      The prehospital ECG has major terminal QRS distortion, yes! There is no S-wave, nor J-wave, in V2 and V3.


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