A man in his 50s with unwitnessed VF arrest, defibrillated to ROSC, and no STEMI criteria on post ROSC ECG. Should he get emergent angiogram?

Written by Pendell Meyers

A man in his 50s was found by his family in cardiac arrest of unknown duration. His family started CPR and called EMS, who arrived to find him in ventricular fibrillation. 15 minutes after EMS arrival, after at least 6 defibrillations, the patient achieved sustained ROSC. He arrived to the ED with severe hypotension, heart rate in the 70s, unable to follow commands but moving all extremities requiring restraint and sedation, respiratory rate around 24/min being supported with bag valve mask, with significant hypoxemia.

He underwent resuscitation including vasopressors, inotropic support, and intubation. Here is his ECG after stabilization of vitals (at least 30 minutes since sustained ROSC).

What do you think?

The ECG is diagnostic of acute LAD occlusion MI. This is the "precordial swirl" pattern of LAD OMI that we are planning to publish soon, with STE and HATW in V1-V2, with reciprocal STD/TWI in V5-V6. AVL is also suspicious, and with reciprocal STD in the inferior leads. Anterolateral OMI.

Here is the Queen of Hearts (version 1) interpretation:

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Angiogram images before and after intervention:

Another view (before and after intervention):

The patient was confirmed to be in cardiogenic shock, placed on ECMO, also with impella assist device. 

Only one hs troponin I was measured on arrival: 323 ng/L

Initial echo showed10% EF, diffuse severe hypokinesis.

Post angiogram ECG

The patient was eventually able to be weaned off of ECMO and impella. He was extubated, following commands, talking to his family soon. Further information is not available. 

See this recent case which also explains in more detail the guidelines for post arrest NSTEMI management: 

Guidelines would (erroneously) say that this patient who was defibrillated and resuscitated does not need emergent angiography

See these many examples of Swirl and of LVH (which has some features of swirl, but is different):

Precordial Swirl -- 20 cases of Swirl or Look-Alikes

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MY Comment, by KEN GRAUER, MD (7/9/2024):

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Interpretation of the ECG following resuscitation from cardiac arrest can often be challenging. Despite anticipation by many that the initial post-resuscitation ECG will show an obvious acute infarction — this expected "STEMI picture" is often not seen.

• For clarity in Figure-1 — I've reproduced the initial ECG in today's case, obtained at least 30 minutes after achieving ROSC in this patient requiring multiple shocks for recurrent VFib.

The Post-Resuscitation ECG:

I thought the initial ECG in today's case was not obvious. Indeed, careful attention to detail is needed to appreciate the important findings. That said, as per Dr. Meyers — this ECG is diagnostic of the Precordial Swirl Pattern (so wonderfully described and illustrated by Drs. Meyers and Smith in the October 15, 2022 post of Dr. Smith's ECG Blog).

• Restoration of sinus rhythm is evident in Figure-1.
• Artifact attributable to some repetitive movement/action in the LL (Left Leg) extremity impairs our assessment of multiple complexes (Maximal artifact in leads II,III,aVF — 1/2-size artifact in aVR,aVL — and no artifact in lead I isolates the "culprit" extremity to the LL).

As per My Comment in the above-cited Oct. 15, 2022 post — I like to focus on the ST-T wave appearance in leads V1 and V6 to facilitate recognition of Precordial Swirl.

• Although 1-2 mm of upsloping ST elevation is commonly (and normally) seen in anterior leads V2 and V3 — most of the time we do not see ST elevation in lead V1 (or if we do — it is minimal!). Therefore — I become immediately suspicious of "Precordial Swirl" whenever there is suggestion of LAD OMI — and — in addition, lead V1 looks different than expected! 
• As highlighted within the RED rectangle in Figure-1 — There is no way the ST segment straightening, elevation and peaked T wave in lead V1 is normal.
• Once we know that the ST-T wave appearance of lead V1 is abnormal — it becomes easier to appreciate that neighboring lead V2 (within the BLUE rectangle) shows similar (albeit less marked) abnormalities.

The other major component of Precordial Swirl — is the ST-T wave appearance in leads V5,V6. I focus first on lead V6. (I expand on this concept in My Comment at the bottom of the page in the Oct. 15, 2022 post).

• CAVEAT: When considering Swirl — Keep in mind that it is EASY to be fooled by LVH, which may produce ST-T wave changes of LV "strain" not only in leads V5,V6 — but also in anterior leads, in the form of an elevated ST-T wave. This is not an issue in today's case, because as seen in Figure-1 — S wave voltage in leads V1,V2 and R wave voltage in leads V5,V6 is small. There is no hint of LVH in today's initial ECG — and as a result, the certainty of abnormality in ST-T wave appearance in leads V1,V2 and V5,V6 is reinforced.
• PEARL: In general — the shape of the ST-T wave depression in lead V6 with Swirl does not look like it typically does with LV "strain", in which the depressed ST segment will often be downsloping. Instead — the depressed ST segment with Swirl tends to be flatter, at least in lead V6 (BLUE arrow in this V6 lead).

Additional ECG findings in Figure-1 that support the diagnosis of LAD OMI and Swirl include:

• Reciprocal ST depression in each of the inferior leads (YELLOW arrows).
• Subtle-but-real ST elevation in lead aVL (dark BLUE arrow in this lead). 

Figure-1: I've labeled the initial ECG in today's case.