A 60-something y.o. male presented with intermittent left-sided chest and shoulder pain that is achy in nature and lasted a few minutes or sometimes just a few seconds.
"The symptoms come and go, not associated with any exertion or history of trauma. Patient does have a history of hypertension and has been taking his medications. Prehospital EKGs appeared consistent with anterior tombstone ST elevation with pain."
Prior to arrival the patient was given full dose aspirin, as well as nitroglycerin, which relieved his pain, after which T wave inversions were noted in the anterior precordial leads.
These 2 prehospital ECGs are not available.
On arrival, the patient had recurrent chest discomfort and had this ECG recorded:
LAD STEMI
His pain quickly resolved and 6 minutes later, this was recorded:
Reperfusion "Wellens'" waves
His pain quickly recurred and another ECG was recorded at 12 minutes (6 minutes after the 2nd one)
Re-occlusion
The patient's pain resolved again and this was recorded 19 minutes after the 3rd one (t = 31 minutes)
Reperfusion again
He went to the cath lab and the angiogram showed a thrombotic LAD culprit with normal (TIMI-3) flow.
The lesion was stented.
The initial high sensitivity troponin I returned at 96 ng/L.
The patient did well.
Comment:
This is a nice illustration of what occurs with occlusion and reperfusion, and a demonstration of how thrombus can lyse and propagate, lyse and propagate. This can occur with or without nitroglycerin and/or aspirin.
We all have an ongoing delicate balance between thrombosis and thrombolysis, using our own endogenous tissue plasminogen activator.
Large upright T-waves are a sign of a large amount of myocardium at risk, but also that it is all viable and salvageable. So it is a bad sign that there is so much at risk, but a good sign that the vast majority is salvagable.
Large inverted T-waves are a sign that a large amount of viable myocardium is now reperfusing. It is a sign that there was still a lot of viable myocardium at the time of reperfusion -- reperfusion was NOT too late.
As more fully ischemic time passes, T-waves become smaller, and when there is reperfusion, the size of the inverted T-wave is also smaller.
Steve, great case!
ReplyDeleteNot only is this one amazing, but really important to keep sharing these since unfortunately the concept of how dynamic ACS truly is still escapes too many. Only thing that surprised me about this case is how quickly the T waves became nearly symmetric and deeply inverted. Would have expected them to evolve from Biphasic to these, but over more time. Do you suspect they did, and just super quickly? Or just skipped that phase?
Sam
Sam, yes, this is unusual and I don't have a good explanation for it and I suspect if you could monitor them second by second they would evolve continuously but quickly from biphasic to deep symmetric.
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