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Dawn's picture

Acute Anterior-Lateral Wall M.I.

Submitted by Dawn on Fri, 04/25/2014 - 14:01

This week's ECG is from a 47-year-old man who experienced a sudden onset of chest pain while mowing his lawn.  He went on to suffer a cardiac arrest and was resuscitated.  We do not have long-term followup on his outcome.

The experienced person will have no difficulty identifying a large acute antero-lateral wall M.I.  There are massive ST segment elevations in Leads V1 through V6, reflecting acute injury from the septal side of the anterior wall (patient's right) to the anterior-lateral wall (patient's left).  There are also ST elevations in Leads I and aVL, reflecting the high lateral wall.  This indicates, and was confirmed in the cath lab, that the lesion is proximal - at or above the bifurcation of the left anterior descending artery and the circumflex artery.  The ST depressions in the inferior wall leads (II, III, and aVF) likely represent reciprocal changes.  You will note that the ST depression in Lead III has a very similar shape to the ST elevation in Lead aVL.

More bad news for this patient is the presence of pathological Q waves in Leads V1 through V4, reflecting transmural death of the myocardial tissue.  This causes akinesis and poor left ventricular function.  In addition, it's not only muscle tissue that dies, but also electrical structures , such as bundle branches.   Papillary muscles can be infarcted, causing valve malfunction.  And remember, all patients who have ST elevation due to acute injury are vulnerable to ventricular tachycardia and ventricular fibrillation, due to re-entry mechanisms in injured tissue.   

This ECG will allow instructors to discuss with their students:

*  which leads reflect changes from which parts of the heart

*  what the ECG signs of acute M.I. are

*  the pathophysiology of pathological Q waves

*  the effect of damage to various parts of the heart on the patient's condition and symptoms

This "classic" M.I. pattern should be taught to all health care professionals who work in settings where ECG is used.

Dawn's picture

Anterior Wall M.I.

Submitted by Dawn on Wed, 03/05/2014 - 21:27

A 78-year-old woman complained of nausea and diaphoresis.  Paramedics in the field found that her 12-lead ECG showed ST elevation in V1 through V4, aVL, and aVR.  The patient denied chest pain and also denied any cardiac history.  She did not want to be transported to the hospital, but thankfully, the paramedics understood that this was not an option, and convinced her to go.

She was taken to a cardiac facility as a STEMI Alert, was evaluated in the cath lab, and sent immediately to the O.R. for coronary artery bypass surgery.  She had severe multi-vessle disease and a lesion in her proximal left coronary artery.  No other details of the cath results are known.

Some important teaching points:

  • there is subtle ST elevation in V1 and V2, but the SHAPE of the ST segment is suspect, with flattening and almost a coving upward shape in V1.  Normal ST segments are convex downward, like a smile.
  • there is nearly complete loss of r waves in V1 and V2, and V3 and V4 have very small r waves.  This signals impending pathological Q waves, a sign of necrosis of the myocardium.  Necrotic muscle does not contract.
  • there is slight ST segment elevation in aVR.  Along with STE in V1, this is a marker for proximal LCA or left main occlusion.
  • the ST elevations in V3 and V4 are more pronounced, and easily meet STEMI guidelines:  currently 1.5 mm of elevation in V3 and 1 mm of elevation in V4 for a woman.
  • there are reciprocal ST depressions in II, III, and aVF - common in AWMI.
  • aVL has slight STE, along with inverted T waves. Somewhat surprisingly, there is no ST depression in Lead I.  This indicates high lateral wall injury.
  • the patient has a "hint" of the criteria for LVH:  her S wave in V3 + her R wave in V5 = about 33 mm, and there is depression in V6.  A stretch to call it "LVH", but possibly a sign of left ventricular strain because of the acute M.I.
  • there are atrial abnormalities suggested by the tall, peaked P waves in Lead II, the "M" shaped P waves in Lead III, and the inverted P waves in V1 and V2.  Possibly bi-atrial dilation and stress brought on by the M.I.?  An echocardiogram would be a better test for this.
  • the heart rate, at about 90 bpm, reflects NSR but is a cause of more stress on an overworked, injured heart.

This is a great teaching ECG, and we hope the Gurus out there will add even more interesting points to consider.

Dawn's picture

Stroke and ST Elevation

Submitted by Dawn on Wed, 02/12/2014 - 23:59

A 77-year-old man was brought to the Emergency Department with stroke symptoms.  He had less than one hour since symptom onset.  He presented with extreme weakness of his right side and slurred speech.   He has a history of coronary artery disease and previous acute M.I.  His BP was 188/80, P 46/min., and resp. 16/min.  He denies chest pain, N&V, and shortness of breath.  The E.D. physician called in the stroke team, and a diagnosis of CVA was made.   What does his ECG show?

This ECG shows clear ST elevations in V1 and V2, with abnormally flat ST segments in nearly all leads.  In addition, there are ischemic T wave inversions in Leads V3, V4, V5, I, and aVL.   A diagnosis of anterio-lateral M.I. is made in addition to stroke.

Ischemic changes, like ST elevation and T wave inversions have been demonstrated frequently in patients with strokes.  Stroke symptoms have also been recorded in patients who are having M.I.s.  Ischemic stroke has been shown to be a complication of acute myocardial infarction.  Hemorrhagic stroke can follow anticoagulation or thrombolysis.   Also, acute M.I. has been shown to be a complication of stroke. Artery disease is a common denominator in both conditions. 

Needless to say, this can be a very complex problem, and the patient with stroke symptoms requires a CT scan to rule out hemorrhage before the M.I. is treated with anticoagulants or thrombolytics. 

References:  MI After Stroke, The Heart.org;  Incidence of Stroke After Acute M.I., Witt, et al ; Ischemic Stroke After Acute Myocardial Infarction, Mooe, et al.

 

 

Dawn's picture

Teaching Tip: A Series of ECGs Can Tell A Story

Submitted by Dawn on Fri, 12/20/2013 - 11:16

When teaching ECG, I always try to make the ECG interpretation have some practical context for the student.  Why study squiggly lines, if they don't mean something to our care of our patients?  Even putting a simple scenario (actual or invented) with an ECG can make it more relevant for your students.  A series of ECGs taken as the patient undergoes changes, is especially helpful.

Dawn's picture

Teaching Series 1113: ECG 6 of 6 - Acute Anterior Wall M.I.

Submitted by Dawn on Sun, 12/15/2013 - 20:25

This ECG is the last in a series of 6 that were donated by Jenda Enis Štros showing the evolutionary changes of an M.I. from onset, through spontaneous reperfusion, angioplasty, re-occlusion by thrombus, and recovery.  This ECG shows deep precordial T wave inversions, an expected evolutionary change after reperfusion of an occluded artery - in this case, the left anterior descending.  The patient has lost some of his QRS amplitude (viable heart muscle), but has not developed pathological Q waves.  Pathological Q waves would indicate full-thickness necrosis of the wall, which is usually a permanent injury.  

The patient was discharged home with a 45% ejection fraction (60% is ideal), and he had akinesis of part of his anterior wall.  This can be permanent or temporary, and followup studies would be needed to evaluate the ongoing health and function of the left ventricle.

Here are links to all six ECGs from this series:

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-1-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-2-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-3-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-4-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-5-6-acute-anterior-wall-mi

 

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-6-6-acute-anterior-wall-mi

 


 

Dawn's picture

Teaching Series 1113: ECG 5 of 6 - Acute Anterior Wall M.I.

Submitted by Dawn on Sun, 12/15/2013 - 20:16

Continuing our series from the patient with acute AWMI, donated by Jenda Enis Štros, a new dysrhythmia has appeared.  The patient was taken to the cath lab, and a thrombus was removed from the stent.   We now see a wide-complex tachycardia.  The morphology (shape and configuration) of the QRS has changed considerably from the previous ECGs, so we know this is idioventricular in origin.  There are many other clues, but  some major ones are:  the QRS is very wide, there is no associated P wave, all the precordial leads except V1 are negative (precordial concordance), V6 is negative, and the axis is away from II, III, and aVF and toward aVR (aVR is upright).  

Because the rate is about 125/min., this could be called ventricular tachycardia (V Tach) or accelerated idioventricular rhythm (AIVR).  The important fact here is that this rhythm was transitory and the patient remained stable.  Reperfusion dysrhythmias are not uncommon, and the patient is treated as indicated by the clinical condition. 

Here are links to all six ECGs in this series:

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-1-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-2-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-3-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-4-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-5-6-acute-anterior-wall-mi 

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-6-6-acute-anterior-wall-mi

 

   

Dawn's picture

Teaching Series 1113: ECG 4 of 6 - Acute Anterior Wall M.I.

Submitted by Dawn on Sun, 12/15/2013 - 20:07

Continuing our teaching series of ECGs donated by Jenda Enis Štros, ECG 4 of 6 shows a new occurance of huge T wave inversions in the precordial leads.  Since this is the area that was stented (left anterior descending artery, anterior wall of the LV), we immediately should think of re-occlusion of the artery.  In a newly-placed stent, the danger is thrombosis (blood clot).  The patient had no chest pain at this time.

Here are links to all six of the ECGs in this series:

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-1-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-2-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-3-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-4-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-5-6-acute-anterior-wall-mi 

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-6-6-acute-anterior-wall-mi

 

Dawn's picture

Teaching Series 1113: ECG 3 of 6 - Acute Anterior Wall M.I.

Submitted by Dawn on Sun, 12/15/2013 - 19:28

This is ECG 3 in a series of 6 ECGs donated to the ECG Guru by Jenda Enis Štros. The left anterior descending artery occlusion has been confirmed in the cath lab, and angioplasty with stent placement has been performed.  Post-stent, there are T wave inversions in the precordial leads (V Leads), which is an evolutionary change during the recovery phase of acute ST elevation M.I. 

Here are the links to all six ECGs in this series:

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-1-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-2-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-3-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-4-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-5-6-acute-anterior-wall-mi

 

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-6-6-acute-anterior-wall-mi

 

Dawn's picture

Teaching Series 1113: ECG 2 of 6 - Acute Anterior Wall M.I.

Submitted by Dawn on Sun, 12/15/2013 - 19:23

To continue the series donated by Jenda Enis Štros, ECG 2 shows spontaneous resolution of the ST elevation, coinciding with relief of the patient's chest pain.  Spontaneous reperfusion can occur when the artery diameter is increased, the offending clot shifts position to allow blood flow, or other reasons.  This does not mean, however, that the lesion has disappeared.

Here are the links to all six of the ECGs in this series:

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-1-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-2-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-3-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-4-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-5-6-acute-anterior-wall-mi

 

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-6-6-acute-anterior-wall-mi

 

Dawn's picture

Teaching Series 1113: ECG 1 of 6 - Acute Anterior Wall M.I.

Submitted by Dawn on Sun, 12/15/2013 - 19:16

This is the first of six ECGs donated to the ECG Guru by our friend, Jenda Enis Štros. 

The patient is a man in his 60's with chest pain.  This is a pre-hospital ECG showing ST elevation across the anterior wall, beginning in V2.  Though the upwardly-concave shape "smile" appears rather benign, the amount of j-point elevation in these five related leads - in a man with chest pain - does not favor a diagnosis of early repolarization. The diagnosis is STEMI, and the cath lab is activated.

Links to the entire series of six ECGs:  

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-1-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-2-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-3-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-4-6-acute-anterior-wall-mi

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-5-6-acute-anterior-wall-mi

 

http://www.ecgguru.com/ecg/teaching-series-1113-ecg-6-6-acute-anterior-wall-mi

 

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