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Extensive Anterior Wall M.I. With Recent Inferior Wall M.I.

Fri, 08/29/2014 - 17:15 -- Dawn

This 88-year-old woman was brought to the Emergency Department in cardiogenic shock.  Very little is known of her past medical history, but it was relayed to the EMS responders that she had been ill for about four days, when she became much worse.

This ECG shows a large, acute anterio-lateral wall M.I., as evidenced by the ST ELEVATIONS in V2 through V6, Leads I and aVL.  To make matters worse, there are PATHOLOGICAL Q WAVES in Leads V2 through V6.  Pathological Q waves indicate areas of necrosis.  Because the myocardium facing the positive electrode is not electrically active, we "see through" the dead tissue to the myocardium on the opposite side of the heart.  Pathological Q waves could be thought of as "reciprocal R waves".  This represents a great deal of dead myocardium, which will be akinetic - not moving.

To make matters worse, she has pathological Q waves in the INFERIOR WALL as well, in Leads II, III, and aVF.  Her ST segments in those leads are flattened and possibly slightly elevated, but not much.  There are no reciprocal ST depressions in I and aVL, because they are affected by the anterior - lateral wall M.I., and are elevated.

The accompanying photos show her left coronary artery angiogram indicating severe coronary artery disease and a "missing" left anterior descending artery.  This is due to a proximal lesion that occurred around the area of the first diagonal artery, cutting off blood flow to a very large part of her anterior-lateral wall.  The photo of the right coronary artery shows a very tight lesion which is allowing some blood to pass.  The Interventionalist felt that this represented a resolving 100% occlusion (remember, she had been sick for four days).  As the blood clot broke up, blood flowed again, lowering the ST segments.  Unfortunately, permanent damage had already been done, and she had Q waves in the inferior wall also.  This leaves very little of her heart beating, and it is easy to understand why she presented in shock.  She suffered cardiac arrests several times during the procedure, and was managed with a balloon pump and ventilator.

Unfortunately, this type of injury is not survivable, and she died in the CVICU a few hours after her procedure. She contributes to our education by demonstrating the cumulative effects of M.I., especially when permanent damage occurs.  For a look at her ventriculogram, to understand the devastating effects of these injuries, go to our You Tube channel.

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Comments

ekgpress@mac.com's picture
     Not much to add to the description of this case and ECG by Dawn. The cath films (and YouTube angio  link in Dawn's write-up at the bottom) tell all. This elderly patient with obvious prior significant coronary disease suffered a superimposed huge new event with resultant cardiogenic shock (minimal to almost no effective cardiac function on cath film). She has almost "Qu-ed out" on her ECG with associated marked ST elevation across the chest leads. Of interest (wrt ECG interpretation there is virtually no ST elevation in aVR and V1  and only minimal in aVL  all of which by ECG suggest a less than maximally proximal LAD lesion  which is borne out by her cath films. Preservation of the initial r wave (positive deflection) in lead V1 suggests the septum is still intact (and there is no RBBB).
  • Of academic interest also is likelihood of associated LAHB (Left Anterior HemiBlock) in addition to Inferior Infarction  because when you have a Q (or QS) in lead II and terminal depolarization (the r') in lead aVR occurs later than the peak of the R wave in lead aVL  there is probably also LAHB (Warner et al - Am J Cardiol, 1983). 
For those wanting more on determination of the "culprit artery" with acute STEMI  Please check out this pdf (excerpted from my ECG-2014-ePub CLICK HERE TO DOWNLOAD. The part on distinction between LMain vs proximal LAD occlusion is covered in Sections 10.24, 10.25.
  • NOTE: For more on distinction between LMain disease vs LMain occlusion — Please See Section 09.40 in our pdf on Using Lead aVR (from my ECG-2014-ePub).
  • This case is linked to my ECG Blog #103 

Ken Grauer, MD  www.kg-ekgpress.com   ekgpress@mac.com 

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