This was sent by Sam Ghali @EM_RESUS
A 44 year old man presented with chest pain
The tech came running with the ECG as the computer called "STEMI!"
The conventional computer algorithm read: ***STEMI***
The cardiologist overread was: "ST Elevation. Consider Anterolateral Injury or Acute Infarct"
What do you think?
Sam sent this to me and asked: "What do you think, Steve?"
My answer:
--Tough one!
--But I'm going to stick my neck out and say "Not OMI"
--STE in V2 has a near "saddleback" configuration, and that is a sign of false positive STE.
--Tell me the outcome!
He responded:
--You nailed it!
--The Saddleback in V2 is exactly what made me doubt it. (I learned that from you!)
--I also had the benefit of old ECGs on this guy, which at baseline he has very concerning "Hyperacute" T waves!
"I was skeptical because of the saddleback. Then I looked at priors and was pretty much totally reassured. So signed it NO STEMI and triaged him OK to not be in RESUS."
What does the Queen of Hearts say?
Notice that she highlights the relatively high voltage QRS in many leads. The Queen knows that OMI is not just diagnosed by ST Elevation, but that the ST and T must be assessed in the context of QRS voltage.
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Case continued
Previous ECG on file:
This ECG is different in V2, but supports that the ECG above is a mimic.
Sam confirms his impression, which was supported by this old ECG:
"A quick bedside Echo showed no wall motion abnormality and that sealed the deal."
"Then the Hs Trop T at 0 hr + 1 hr: both normal [19 ng/L then 21 ng/L, (ref range <22)]"
More Saddleback cases:
Is this Septal STEMI/OMI? Many examples of Septal STEMI/OMI
What is this ST Elevation?
Saddleback in V2 is rarely LAD OMI, but can be!
2 cases of Saddleback that was indeed OMI
===================================
MY Comment, by KEN GRAUER, MD (1/29/2024):
===================================
Today's case by Drs. Ghali and Smith illustrates the dilemma of assessing Saddleback ST elevation in one or more anterior leads.
- The "good news" — is that most of the time, a saddleback pattern of ST elevation with upward concavity (ie, "smiley"-configuration — as shown in Figure-1) — will be benign, and not the result of acute anterior OMI.
As per My Comment in the July 22, 2023 post in Dr. Smith's ECG Blog — No matter how many times I have seen Brugada-1 and Brugada-2 ECG patterns — I still find myself referring back to the images I include in Figure-1:
- I therefore thought that it may be helpful to explore today's initial ECG a bit further.
-USE.png) |
| Figure-1: I've combined today's initial ECG with the ECG Patterns in Brugada Syndrome (adapted from Brugada et al in JACC: Vol. 72; Issue 9; 2018) — A) Brugada-1 ECG pattern, showing coved ST-segment elevation ≥2 mm in ≥1 right precordial lead, followed by a negative T-wave. — B) Brugada-2 ECG pattern (the “Saddleback” pattern) — showing concave-up ST-segment elevation ≥0.5 mm (generally ≥2 mm) in ≥1 right precordial lead, followed by a positive T-wave. — C) Additional criteria for diagnosis of Brugada-2 (TOP: the ß-angle; LOWER RIGHT: A Brugada-2 pattern is present if 5 mm down from the maximum r’ rise point — the base of the triangle formed is ≥4). |
MY Thoughts on ECG #1
In a patient with new CP (Chest Pain) — the >3 mm of ST elevation seen in lead V2 of ECG #1 is of obvious concern. That said, as per Drs. Ghali and Smith — the saddleback shape of this elevated ST segment is very often a benign finding.
- As suggested in Figure-1 — a saddleback shape of ST elevation in one or more anterior leads suggests a Brugada-2 pattern. As illustrated in Panel C of Figure-1 — distinction between benign concave-up ST elevation vs a Brugada-2 pattern is determined by width of the ß-angle. Unfortunately, lack of a descending segment from the point of ST elevation in ECG #1 precludes calculation of the ß-angle.
- That said — regardless of whether or not ST-T wave morphology in lead V2 of ECG #1 represents a Brugada-2 pattern — the shape of the ST elevation in lead V2 is concave up ("smiley"-configuration) — which is often benign.
- That said — complicating assessment of potential significance (or lack thereof) of the elevated ST-T wave in lead V2 — is the shape of the ST-T wave in lead V1 in ECG #1. There is in fact slight ST elevation in V1 — with gradual descent to modest T wave inversion. This picture is not unlike the picture of a Brugada-1 pattern, with exception that it lacks sufficient ST elevation to qualify for Brugada-1. I therefore could not rule out the possibility of Brugada Phenocopy on the sole basis of this single ECG. As we've discussed on mutiple posts in Dr. Smith's ECG Blog — Brugada Phenocopy is not uncommon in association with other underlying conditions, including infarction (See My Comment at the bottom of the page in the July 22, 2023 post, among many other posts).
- The above said — I suspected that ECG #1 may be benign because: i) None of the other chest leads looked abnormal (The 1-2 mm of upward sloping ST elevation that we see in lead V3 is a common normal finding); ii) There is excellent R wave progression (vs common loss of R wave in leads V2,V3 when there is anterior OMI); and, iii) Nothing acute is seen in the limb leads. While true that reciprocal inferior lead ST depression is not always seen in association with acute anterior OMI — reciprocal limb lead changes are more likely to be seen when the site of LAD OMI is proximal, as could be suggested by leads V1 and V2 being the 2 remarkable chest leads.
To Emphasize: My interpretation above of ECG #1 in today's case is based solely on ECG features of this tracing, knowing only that this patient presented with new CP.
- Subsequent investigation (which clearly was indicated given the amount of ST elevation in today's initial ECG in this patient with new CP) — went on to confirm that ECG #1 was benign, and not indicative of acute OMI.
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