81 year old male CC: "Cold and shaky" – Conclusion

Here is the update to 81 year old male CC: “Cold and shaky”.

Let’s take another look at the 12-lead ECG.

2010_06_03Bwm

At first glance the ST-elevation in the inferior and low lateral leads isn’t that impressive, at least when compared to some of the other cases we’ve seen. However, this is an impressive amount of ST-elevation when compared to the small size of the QRS complexes! This is known as the rule of proportionality and it’s critically important when it comes to STEMI recognition!

Perhaps more impressive is the ST-depression in the right precordial leads (V1-V3). These are reciprocal changes to posterior extension of this acute inferior STEMI. If this was the only abnormality on this ECG I would still call it STEMI! If you want to get really good at identifying acute isolated posterior STEMI, pay attention to the right precordial leads whenever you have an acute inferior STEMI. These changes will often be present.

Of course, you already knew that the ST-elevation in the inferior leads indicated STEMI. Why? Because of the downsloping ST-segment in lead aVL! This is the “go to” lead to “rule-in” acute inferior STEMI! It is so sensitive and specific that absence of this finding should make you question the ECG diagnosis of acute inferior STEMI.

So what happened?

The patient was sent to the cardiac cath lab where angiography revealed 100% occlusion of the right coronary artery (RCA). A stent was successfully placed and the patient is doing well.

Before

 

Balloon inflation

 

After successful stent placement

 

Diagnosis: Acute Inferior ST-Elevation Myocardial Infarction

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EMS 12-Lead

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Comments
Aman
The 12 Leads of Christmas: V2
Thank you for your response. By all means, take your time! As for the source of the first figure, I got it from the book "Essential Cardiology: Principles and Practice - 3rd edition" by Clive Rosendorff - Chapter 7, Figure 7.3 (Page 97). It's one of the rare texts where I found a mention of…
2015-04-27 06:52:25
Vince DiGiulio
The 12 Leads of Christmas: V2
Your questions on this topic are some of the best I've encountered—no need to apologize! It makes me very happy to see this post reaching the right people. I'm working non-stop the next two days but I will get back to you soon with my full response. Two things to start: First, where did you…
2015-04-27 05:14:11
Aman
The 12 Leads of Christmas: V2
Thank you so much! I wonder why this information is not found in ECG texts. I have a query though. The critical information seems to be the fact that leads V1 and V2; V3; and V4-V6, each are physically located on a different transverse plane with respect to the theoretical electrical center. (Also mentioned in…
2015-04-26 18:24:06
Matthew
68 y.o. male with weakness: “Treat the monitor, not the patient?”
I lean toward what jason said above - Going to the PCI Hospital, but not activating the lab yet. Go with the Hyper K treatment enroute.
2015-04-26 13:34:57
Ken Grauer, MD
Understanding Digoxin
Digoxin is used much less frequently these days than in the past - when it was a drug that virtually every patient with heart failure was taking. As a result - many clinicians in modern times are far less familiar (and comfortable) with how to dose Digoxin. Digoxin pharmacokinetics are linear - You double the…
2015-04-16 03:27:43

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