58 year old female CC: Chest pain – Conclusion

Here’s the conclusion to the 58 year old female with chest pain and left bundle branch block.

To refresh your memory here is the 12-lead ECG.

And for those of you who requested lead V4R.

This ECG meets all 3 of Sgarbossa’s criteria to identify acute STEMI in the presence of left bundle branch block.

Keep in mind, it only has to meet one criterion in one lead!

(Please note: One criterion has been modified from its original form. Instead of discordant ST-elevation > 5 mm we are looking for discordant ST-elevation > 0.2 the depth of the S-wave. This is known as the ST/QRS ratio. Credit to Dr. Smith of Dr. Smith’s ECG Blog.)

Angiography revealed 100% occlusion of the LCX and 99% occlusion of the RCA.

Thanks to everyone who commented on the case!

See also:

80 year old male CC: Chest pain

Excessive discordance as a marker of acute STEMI in LBBB

80 year old male CC: Chest pain – Conclusion

62 year old male CC: Chest pain (LBBB with ST-elevation > 0.2 the QRS complex)

Identifying AMI in the presence of LBBB – Sgarbossa’s Criteria Part I

Identifying AMI in the presence of LBBB – Sgarbossa’s Criteria Part II

“New” LBBB – What’s the big deal?

Discordant ST-segment elevation in LBBB or paced rhythm

Sgarbossa’s Criteria – New Graphic

Found on the Lifenet Receiving Station (LBBB with concordant ST-depression in leads V3 and V4)

5 Comments

  • akroeze says:

    Thanks so much for this real world example Tom!I have actually made printouts of the graphics you use for the three criteria and taped them to the back cover of my protocol book since for some reason I have a hard time committing them to memory. I encourage others to do the same.I'm not sure how things will go the first time I find one of these though as the patient would not meet my current protocol… so I guess I would be at the mercy of the physician knowing what I'm talking about!

  • Tom B says:

    My pleasure, Alex. I'm amazed it took this long.

  • Do you have a refrencve for the "newer: criteria ST greater than 0.2 of S wave

  • Tom B says:

    Bostonmedic109 -Initially it was 0.25 the QRS complex.For a reference see:Circulation. 2008;118:S_578ACS: Initial Assessment-Old and New ToolsAbstract 551: Ratio of Discordant ST Segment Elevation or Depression to QRS Complex Amplitude is an Accurate Diagnostic Criterion of Acute Myocardial Infarction in the Presence of Left Bundle Branch BlockSince then Dr. Smith has reported on his blog that more cases and further analysis have revealed that using 0.2 increases the sensitivity while maintaining the same specificity.Tom

  • Várhegyi Márton says:

    Nice and useful article!:-)

    Any q/Q waves in left-sided leads (I, aVL, V5-6) and other markers of necrosis in LBBB (Cabrera's sign etc.) might also be important, however, can be the result of prior myocardial infarction or atypical form of LBBB.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Sean V
Rate Related VS. Primary ST-T Changes:
Also forgot to mention decrease the FiO2, 3LPM is getting us a SpO2 of 98%, titrate down so we staying at or above 94%. No need to hyperoxygenate & create all those fun free radicals. I would also include using an EtCO2 nasal cannula, lets get another measure of our cardiac output.
2014-09-20 02:32:20
Sean V
Rate Related VS. Primary ST-T Changes:
Atrial Fibrillation w/ Rapid Ventricular Response. There appears to be possible Delta Waves, the most prominent being in aVL, also leads I, II, and V6. In the EMS 12-Lead there appears to be a fusion beat, 3rd in V2, slurred R-wave appears quite consistent with a Delta wave. I would consider WPW as the primary…
2014-09-20 02:28:16
Brian
Rate Related VS. Primary ST-T Changes:
Afib. There is widespread depression in most leads and aVR has some elevation...but I am skeptical about this ecg. If a quick fluid challenge of 500-1000cc did not slow down the HR I would give him some diltiazem (5mg increments is our protocol or 0.25mg/kg) and slow the rate down a bit and see if…
2014-09-19 21:02:48
Michael Schiavone
Rate Related VS. Primary ST-T Changes:
Isolated ST elevation in AVR with ST depression in several leads. Rapid, irregular rate suggests AFIB with RVR. I would provide entry note with this exact description and leave it to hospital whether or not to activate cath lab. My EMS treatment: IV access, 324 mg. ASA, NTG, Cardizem .25 mg/kg over 2 minutes, consider…
2014-09-19 20:30:35
Dayne
Rate Related VS. Primary ST-T Changes:
AF with RVR @167, LVH and prolonged QT. ST depression to I,II and V3-6 and reciprocal elevation to aVR equal to or >1mm highly suggestive of LMCA or 3-vessel disease. High specificity for proximal occlusion. Aspirin, GTN, IV access, Spo2 >95%, Transport to nearest PCI/Cath Lab facility ASAP
2014-09-19 10:52:36

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