September 25, 2015

ST elevation in the inferior leads due to wraparound LAD

An adult patient was admitted due to numbness and weakness of arm and left sided chest pain. VS were 149/90, HR = 66 , RR = 12 and afebrile. Baseline 12L was negative for STE's. CBC, Chemistry were normal and troponin came back negative, CXR showed no acute disease. 

While on telemetry, the patient had chest pain. 

Image 1 - ECG case

There are ST elevations in I, II, III and aVF and ST depression in aVR and aVL. STE in I with STE in II, III and aVF was an odd combination. 

Here is the serial telemetry changes.

Image 2 - Serial telemetry changes

Cardiology was on board and heart cath was done. There were no significant stenosis in right coronary artery (RCA) , left anterior descending (LAD) artery was wrapping around the apex with subtotal occlusion after the second diagonal. Intervention was done. The patient was eventually discharged.

The STE in the inferior leads was not due to RCA pathology but was due to wrap around LAD.

Image 3 -  Wraparound LAD 

*Image adapted from Akdemir et al. 2004. Simultaneous Ant and Inf MI due to occlusion of LAD. Turk J Med Sc (34):121-126


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