ST Elevations in Multiple Leads

 

70 yo c/o CP. 

What is the interpretation? 

1. STEMI
2. EMA artifacts
3. Myopericarditis
4. Spike-helmet ECG

STEMI-ST elevation myocardial infarction

EMA - electromechanical association

STEMI in Right Bundle Branch Block

Vignette:  A 60 yo with h/o of DM and HTN is c/o chest pain. 

The 12L shows sinus rhythm at about 80 bpm with right bundle branch  block (RBBB) pattern. There are ST elevations in all precordial leads (V1-V6), I and aVL. There are ST depressions in III and aVF. This is anterior wall STEMI. Angiography showed lesion in the proximal LAD and intervention was done.

Inferior Wall ST Elevation Myocardial Infarction in a Patient with Pacemaker

Figure 1

Vignette: 75 yo with h/o HTN, hyperlidemia, AF, s/p PM

c/o nonpleueritic CP with no cough/fever

Figure 2

Non-paced beats (red boxes) are noted to have ST elevations in II, III and aVF with reciprocal changes in I and aVL. There are also ST depression and T wave inversion in V2 and STE V3 to V6.

Troponin ~5 and echo showed infero-posterior wall hypokinenia.

Cath showed lesion in the posterior descening artery.

Interpretation : Inferior Wall ST Elevation Myocardial Infarction (IWSTEMI) in a Patient with Pacemaker

Anterior wall STEMI

A 60 yo with h/o of DM and HTN is c/o chest pain

Image 1

The 12L shows sinus rhythm at about 80 bpm with right bundle branch  block (RBBB) pattern. There are ST elevations in all precordial leads (V1-V6), I and aVL. There are ST depressions in III and aVF. This is anterior wall STEMI. Angiography showed lesion in the proximal LAD and intervention was done.

@ecgrhythmsv2 #23

Inferior Wall MI

Image 1 - ECG case

A 70 yo with h/o DM and HTN was admitted due to dizziness and syncope while having breakfast. Pt regained consciousness a few moments later and brought to local hospital. Patient was not in distress and only had mild chest discomfort with the ff VS afebrile RR 18 PR 84 BP 140/80 sat 100 NC. Trop less than 0.03, lytes and crea in the normal range.

Image 2 - ECG case marked

ECG shows sinus tachycardia with STE II, III and aVF (III >II), STD's aVL,I and in precordial leads up to V3 and multifocal PVC's. This indicates inferior wall MI (STEMI).

Heart cath revealed occlusion in the distal RCA and intervention was done. Echo showed mild LVH and EF in the 60's.

Patient was discharged after a few days.

You might ask what could have caused the syncope. It was thought that the pt might have VT but that was not observed in the hospital stay.



#501

STEMI (IWMI) and Complete Heart Block

An elderly with h/o of HTN and DM II c/o chest discomfort. 

Figure 1

Inferior wall STEMI with lesion in the left circumflex artery with separate ostium

A 60 yo with a  h/o of HTN and smoking came in due to chest pain?

Figure 1

STEMI : Anterior wall

An adult pt with a history of HTN came in due to chest pain with radiation to the left arm associated with dyspnea. No nausea or vomiting. VS 140/80 afebrile HR 80’s RR 20 and sat 98% at room air. No JVD, CBS.

Figure 1

ECG showed SR in the 90’s with ST elevations (STE) in V1-V5 (max STE in V2), hyperacute T waves prominent in V2/V3 and ST depressions (STD) in III, aVF and II. QTc is 498 ms.

Intervention revealed occlusion in the left anterior descending (LAD) artery. Stent was then placed.

Maximum troponin was 1.5 and echo showed and EF in the 60’s. Patient was then discharged after a few days.

#280

Inferior Wall STEMI

An adult pt with history of hypertension and dyslipidemia was brought in due to chest pain.

The rhythm is sinus, right bundle branch block (RBBB) with ST elevations in III, II and aVF and ST depression in aVL. This is inferior wall ST elevation MI. 

Classic ECG Pattern

• Greatest magnitude od ST elevation (in descending order) - III, aVF and II

• Reciprocal ST depresion in aVL

Patients with STE in inferior leads (II, III and aVF) have occlusion in the right coronary artery (RCA) in 80-90%. Occlusion of the left circumflex artery (LCx) can produce similar pattern.

A nice table showing common ECG features distinguishing culprit artery in IWMI.

For the case

CAG showed RCA lesion, EF 50% and inferior hypokinesis on LVgram. Intervention  done.

Reference:

Alter S et al. 2006. Electrocardiographic Diagnosis of ST-elevation

Myocardial Infarction. Cardiol Clin 24 (2006) 343–365

#244

AV block is more common in IWMI

Vignette: 65 yo with h/o  HTN, DM, dyslipidemia 

c/o of chest pain

Image 1

The rhythm is sinus tachycardia at about 107 bpm with complete heart block (CHB) with a junctional escape rhythm (50 bpm). There are ST elevations in II, III and aVF with ST depression more pronounced in aVL than I. ST-T wave changes can be seen in precordial leads extending to V4. This is inferior wall STEMI (IWMI)with  complete heart block. AV block is more common in IWMI because the AV node is  supplied by the right coronary artery (RCA).

Image 2

P waves are marked. Some of the P waves are (partly) hidden from view (blue arrowheads)

Echo showed EF between 45 - 50 %,with severe inferior and inferolateral  hypokinesis. Angiogram revealed lesion in the RCA and intervention was done.Patient was discharged a few days later in sinus rhythm (with no CHB). 

#585  

Something odd in the precordial leads? Posterior Wall MI

Elderly with hypertension and dyslipidemia came in due CP . No nausea and vomiting. Claimed to have been driving for hours. VS were normal BP 140/60.

****

Coronary angiogram revealed 95% stenosis of LCx and stent was deployed. Echo done reveal normal systolic function with EF in the 60's.

Posterior wall infarct may occur in isolation in about 4% of cases. It may present as ST changes in right precordial leads (V1-3)

-horizontal ST segment depression (seen in this case)

-a tall, upright T wave

-a tall, wide R wave

-R wave amplitude/S wave amplitude ratio greater than 1

Culprit lesion may be RCA, posterior descending branch, or the LCx (in this case).

#70