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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

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

 

Dawn's picture

Anterior Wall M.I. With Previous Inferior Wall M.I.

Submitted by Dawn on Mon, 11/04/2013 - 13:40

This ECG illustrates an acute anterior wall M.I. in a patient with a previous history of inferior wall M.I.  The anterior wall M.I. can be seen in the classic signs in V1 through V6:  ST elevations with coved upward shape (tombstones), T waves inverting beginning around V2 and continuing through V6, and pathological Q waves in V1 through V6.

The patient had a history of previous inferior wall M.I., unknown age.  This is normally seen in Leads II, III, and aVF.  The first two complexes on the strip are wide QRS complexes without associated P waves, presumably ventricular.  It is impossible to know from this ECG whether the first complex is a PVC or escape beat, but the second appears to be escape.  So, to evaluate the ST segments, T waves, and pathological Q waves in the inferior wall, all we have are aVF and the Lead II rhythm strip at the bottom.  These show pathological Q waves (necrosis), and some slight elevation of ST, with coving or horizontal flattening.  From this, we know there is damage in the inferior wall, but the age of the M.I. is undetermined.

This patient went to the cath lab, and received angioplasty with stenting of the proximal left anterior descending branch of the left coronary artery.

Dawn's picture

Anterior Wall M.I.

Submitted by Dawn on Tue, 08/27/2013 - 15:03

This series of three ECGs is from a 75-year-old woman who came to the Emergency Dept. with chest pain.  The first ECG shows ST elevation in V1, V2, and V3, with generally low voltage in the QRS complexes. There is some coving upward of the ST segment in aVR, which can suggest a very proximal lesion of the left coronary artery (LCA).  She was taken to the cath lab, where it was discovered that she had a 100% occlusion of the midportion of the anterior descending branch of the left coronary artery, which was repaired and stented.  The second ECG, taken after the angioplasty, shows some Q waves in V1 and V2, with poor R wave progression in the V leads.   A 25% occlusion of the obtuse marginal branch of the circumflex artery was stented two days later. The third ECG was obtained after that procedure.  It shows that the Q waves have disappeared in the anterior leads (possibly due to different technicians performing the ECGs with different lead placement).  It also shows marked T wave inversion in I and aVL, representing ischemia in the lateral wall, and in all the chest leads, representing ischemia in the anterior wall.  The QTc is prolonged in this third ECG at 479 ms.  It is not known what medications the patient was on.  This patient also had a 50% proximal occlusion in the RCA and a 75% occlusion in the posterior descending artery.   This is a good example of a patient with extensive coronary artery disease who finally presented for treatment when she developed ST elevation M.I.  

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