What's your analysis?
12 Lead ECG
12 Lead ECG Interpretation and Discussion
A baseline sinus rhythm is present. There is a significant amount of artifact that interferes with interpretation in the limb leads. A fusion beat is seen in the limb lead tracings. However, there is > 1mm of ST segment elevation in lead III. Lead aVF also has minimal ST segment elevation. Pathologic Q waves are present in contiguous leads (III and aVF). Though an isolated Q wave is common in limb lead III, the presence of Q waves in contiguous inferior leads (III and aVF) suggests ischemia. In addition, ST segment depression is present in the reciprocal leads of I and aVL. This finding further supports the presence of acute injury. ST segment elevations are also seen in leads aVR and V1. As discussed in a previous case, the presence of STE in leads aVR and V1 may predict obstruction of the left main coronary artery. Poor R wave progression is present across the precordial leads V2-V6. This finding (the loss of R wave amplitude) is consistent with the machine generated diagnosis of "anterior infarct, age undetermined." These findings, when put together, reveal an inferior wall STEMI. This patient is best cared for at a facility capable of percutaneous cardiac intervention.
Sinus rhythm, inferior wall STEMI. Anterior wall ischemia. Reciprocal changes in the form of ST depression present in the anterior-lateral limb leads.
These are tough cases and I would support any medic transporting this patient to a PCI center but I doubt this patient is actually experiencing an acute STEMI.
ReplyDeleteThe deep Q-wave in lead III with ST-elevation of that morphology is much more consistent with old inferior MI with persistent ST-elevation (a sort of LV aneurysm pattern).
Presenting as she did, with minimal Sx, what we are probably seeing is diffuse subendocardial ischemia (secondary to severe HTN) superimposed on that chronic inferior ST-elevation. Once her BP is under control the EKG can be repeated and if it's still abnormal then it might be time to consider PCI. I've seen almost this exact tracing (often in acute pulmonary edema) maybe a half-dozen times though and I've yet to see one with an acute RCA lesion. But, again, that's not a decision to be made in the field and the EKG certainly qualifies for investigation at the PCI center if one's available.