1) The closest facility?
2) The closest cath capable facility?
You pour over the ECG and make the call.
LEAD V1
- Lead V1 shows approximately 1 mm of elevation at the J point. The baseline is a bit wavy, however the elevation is measured at one small box.
LEAD V2
- Again, there is a slight amount of ST elevation present in leads V2-V3. Elevation is approximately 1.5mm-2mm.
LEADS aVL and aVF
- You screen the ECG for evidence of reciprocal change, but there is no evidence of ST segment depression in the (1) inferior leads or (2) lateral leads. Again, the wavy baseline interferes with the finer details. Reciprocal change, if present, can solidify your impression of STEMI.
The Final (non satisfying) Answer
The ECG reveals a sinus rhythm. There is a slight amount of ST segment elevation present in the precordial leads. The ECG does not meet the strict definition of STEMI. In male patients, recall that STE of greater than 2 mm / 2 small boxes must be present in the precordial leads. Specifically, AHA/ACC guidelines state that STEMI is diagnosed if > 2 mm of elevation is present in leads V2 or V3. Elevation of one small box in 2 contiguous limb leads also satisfies diagnostic criteria. There is also the absence of dynamic change when serial ECGs are examined. There is also no evidence of reciprocal change. The ST segment elevation appears physiologic and accentuated by a wavy baseline. That said, I'd probably transport the patient to a cath capable facility. When ECG findings are equivocal, it is important to look at the PATIENT. In an 80 yo male with a significant past medical history and concerning presentation, it is best to err on the side of caution. Myocardial infarction should probably be at the top of everyone's list, and a certain amount of overtriage to regional STEMI centers is acceptable. Though this ECG does not meet strict criteria for the diagnosis of STEMI, the patient's (1) advanced age and (2) concerning presentation probably warrant a trip to a cath capable facility. Sometimes, it is impossible to achieve diagnostic certainty. If patient stability and local protocols permit, a trip to a cath-capable facility is probably a good idea. Optimizing the quality of your tracing is a wonderful strategy; patient movement should be kept to a minimum when obtaining the tracing. Tachypnea, diaphoresis, and cellular phones have all been implicated as causes of interference with the ECG tracing. Finally, the presence of absence of relief following administration of NTG is unreliable for the diagnosis of acute myocardial ischemia.
The ECG reveals a sinus rhythm. There is a slight amount of ST segment elevation present in the precordial leads. The ECG does not meet the strict definition of STEMI. In male patients, recall that STE of greater than 2 mm / 2 small boxes must be present in the precordial leads. Specifically, AHA/ACC guidelines state that STEMI is diagnosed if > 2 mm of elevation is present in leads V2 or V3. Elevation of one small box in 2 contiguous limb leads also satisfies diagnostic criteria. There is also the absence of dynamic change when serial ECGs are examined. There is also no evidence of reciprocal change. The ST segment elevation appears physiologic and accentuated by a wavy baseline. That said, I'd probably transport the patient to a cath capable facility. When ECG findings are equivocal, it is important to look at the PATIENT. In an 80 yo male with a significant past medical history and concerning presentation, it is best to err on the side of caution. Myocardial infarction should probably be at the top of everyone's list, and a certain amount of overtriage to regional STEMI centers is acceptable. Though this ECG does not meet strict criteria for the diagnosis of STEMI, the patient's (1) advanced age and (2) concerning presentation probably warrant a trip to a cath capable facility. Sometimes, it is impossible to achieve diagnostic certainty. If patient stability and local protocols permit, a trip to a cath-capable facility is probably a good idea. Optimizing the quality of your tracing is a wonderful strategy; patient movement should be kept to a minimum when obtaining the tracing. Tachypnea, diaphoresis, and cellular phones have all been implicated as causes of interference with the ECG tracing. Finally, the presence of absence of relief following administration of NTG is unreliable for the diagnosis of acute myocardial ischemia.
INTERPRETATION
Sinus rhythm with ST segment elevation in the septal precordial leads. Agree with LifeNET. :-/ Acute septal MI was indeed considered.
PREHOSPITAL TREATMENT
Serial 12 lead ECGs. Aspirin and nitroglycerin as needed for pain. Transport to a cardiac interventional center. Oxygen only if hypoxic or severe respiratory distress.
CASE RESOLUTION
The patient was admitted to the medicine floor for further observation. Serial ECGs were unchanged, and troponin measurements were normal. The patient had a bedside echocardiogram which did not show any acute wall motion abnormalities suggestive of acute infarction. The patient was scheduled for an inpatient nuclear medicine stress test.
RESOURCES
There's a great discussion, complete with visual examples, of septal STE patterns at the Life in the Fastlane blog. Check it out!
There's a great discussion, complete with visual examples, of septal STE patterns at the Life in the Fastlane blog. Check it out!
