This ECG was taken from a 60 year old man who was complaining of severe substernal chest pain, radiating to his left arm and a non-productive cough.  There was some initial discussion among the EMS crew  about the possibility of the ECG showing a "benign early repolarization" pattern because of the concave upward ("smiling") ST segments.  They also considered a diagnosis of pericarditis, because the ST segments seem widespread.  The baseline artifact makes it difficult to evaluate for PR segment depression or Spodick's Sign.

The patient's age (60 years) and troubling symptoms (chest pain radiating to the left arm) ruled out BEP for the paramedics.  The ST segment elevations are pretty widespread - Leads V3, V4, V5, V6, I and II all show some STE.  There are also "hyperacute" T waves in the leads with STE.  There are ST abnormalities ranging from flattening of the shape to depression, but the bottom line is this patient is a 60-year-old man with substernal chest pain radiating down his left arm!

The patient was treated in the ambulance with chest pain protocols, and was transferred to a hospital with an interventional cath lab.  The patient was conculusively diagnosed with an acute M.I. and underwent angioplasty.

This is a good ECG to demonstrate subtle changes when, combined with patient presentation, can help us diagnose a coronary event.  It helps us emphasize that not all STEMIs will have dome-shaped, "tombstone" ST segments, and that patient symptoms, history, and age are important to consider.

This ECG depicts an extensive and ultimately, fatal, injury.  There is marked ST segment elevation in Leads V2 through V6 (anterior wall).  There is also ST elevation in Leads I and aVL (high lateral wall).  The ST elevation in aVR is indicative of a very proximal lesion in the left coronary artery, which supplies the anterior wall, including the anterior portion of the septum, the high lateral wall, and, in this case, the low lateral wall.  The inferior leads, II, III, and aVF, show reciprocal ST depression.

This is an old ECG - the computer readings of the rate and intervals is lost, as is the grid.  But the rate here appears to be about 80 bpm and the QRS is widened.  There is a right bundle branch block ECG pattern, which is not surprising given the extensive septal damage.  Normally, the criteria for RBBB on the ECG includes an rSR' pattern in V1 (seen here) and a small, wide s wave in Leads I and V6.  This s wave is not seen here, presumably due to the effects of the ST elevation in those leads.

What matters clinically in a patient like this is not whether there is RBBB or another type of interventricular conduction delay. This patient needs immediate restoration of blood flow through the LCA and intensive medical/nursing care.  As mentioned before, this patient did not survive, in spite of being brought to a hospital.  We do not know the exact mechanism of death or treatment course in this case.

If you are teaching students to use multiple leads in assessing rhythm, this is a great example of how one or two leads can be very misleading.  I have used this ECG's V4 in an excercise illustrating this concept.  Shown V4, many people would call this "AIVR" or "V Tach".  Seen in context with the other leads, it is obvious that we are looking at ST elevation that is as high as the R wave.  Two leads are better than one, and twelve are better than two.

This series of ECGs was taken during ambulance transport of a 67 year old man with chest pain.  Earlier the same week, this man had been discharged from the hospital after having a cardiac cath, angioplasty, and stents. He was discharged the next day.  The patient stated that, until that hospital admission, he was healthy, athletic, and had no significant medical history.  He is currently taking a statin, atenolol, and "one of the new blood thinners" - he didn't know the name.

 ECG No. 3 is the first one shown here, taken at almost 39 minutes after midnight.  The patient was complaining of chest pain of 8 on a 1-10 scale.  His skin was pale, cool, and clammy.  The ECG shows acute inferior-posterior M.I., with ST elevation in II, III, and aVF and reciprocal ST depression in V2, and V3.  V1 would normally be depressed in posterior extension of an inferior wall M.I. - unless the right ventricle is also infarcted.  The message from the right ventricle to V1 would be "elevate", countering the message from the posterior wall, "depress".   The rhythm is sinus with ventricular bigeminy.  The rescue crew notified the hospital of a "STEMI Alert". The patient received I.V., O2,  nitroglycerin spray and paste, as well as aspirin.  The patient's BP was 144/92.

ECG No. 4 was taken at 12:41 a.m.  It shows a change in P waves probably reflecting a low atrial focus.  The patient has a slow underlying rhythm with ventricular bigeminy that is probably multifocal.  It is very hard to determine multifocal PVCs when there is no concurrent rhythm strip, but this is a three-channel ECG machine, and the rhythm strips are run separately from the 12-lead.  There are runs of V Tach toward the end of the ECG, and this is not a good sign in a patient with ST elevation.  In some cases, the V Tach can become persistent, in others it is transient.  The ST elevation and reciprocal depressions are still evident.

ECG No. 5, taken at 12:49 a.m., shows further development of the ST segments, and the classic "domed" shape of STEMI.  In addition, a pathological Q wave has appeared in Lead III, possibly indicating permanent damage from this M.I.  In this ECG, the paramedics have moved the V4 wire to the V4 Right position to better view the right ventricle.  V4 Right is slightly elevated, and definitely dome-shaped, like a frown.  This is an indication that the RV is injured, and medications that lower BP (especially nitroglycerin) should be avoided in the pre-hospital setting because of the danger of loss of preload of the RV and sudden drop in cardiac output. The patient's BP at this time was 138/85.

This ECG was obtained from an elderly man who was complaining of acute-onset chest pain, radiating down his left arm.  He also complained of a cough, and had audible rhonchi.  The machine interpretation gives several possible explanations for the widespread ST elevation noted on the ECG.  The paramedics were a bit distracted by the machine's interpretation, and by the respiratory symptoms, and decided not to call a "cardiac alert" on the patient.  They did, however, quickly transport him to the closest hospital, which happened to have full-service cardiac facilities.  The patient was diagnosed with an acute M.I. and treated with angioplasty in the cath lab, with a good outcome.  Afterward, the medics felt that they "overthought" this one, and should have given more weight to the patient's symptoms.  Teach your students to evaluate their experiences with open minds and unafraid of self-criticism, so they may learn from every patient.  This patient received excellent care, and the paramedics added to their "information banks", upon which they will draw for many years to come. 

Although the angiogram results are not available to us, it is plausible that a proximal occlusion of the LCA, near the bifurcation of the LAD and the diagonal, could cause ST elevation in V3 through V6, with mild elevation in Lead II (which is oriented to the leftward portion of the inferior wall), and ST and T changes in the high lateral leads (I and aVL).