57 year old female CC: Shortness of breath and chest pressure – Discussion

This is the discussion for 57 year old female CC: Shortness of breath and chest pressure.

Let's take another look at the 12-lead ECGs.

I posed the following questions for this case:

  • What do you think of these 12-lead ECGs?
  • What is the most likely cause of the ST-depression and T-wave inversion.

These ECGs show a "strain pattern" (or secondary repolarization abnormality) due to left ventricular hypertrophy which is one of the most common STEMI mimics.

A strain pattern often presents with significant ST-elevation in the right precordial leads (V1 – V3) which is the main reason that it can mimic acute anterior STEMI. Often the ST-elevation can be quite dramatic.

Consider this case from Dr. Smith's ECG Blog for an example.

Also consider this ECG from the 12 Lead EKG blog (with permission).

Here the ST-elevation in the right precordial leads (V1-V3) is impressive. However, the S-waves are very deep! This is the big tip-off that we're dealing with a STEMI mimic.

In this case the patient was cathed because he experienced a VF arrest while on the treadmill at cardiac rehab. You can't blame anyone for sending a patient like that to the cardiac cath lab! 

What they found was extensive coronary artery disease and chronically occluded vein grafts but no acute thrombosis in the LAD.

Interestingly, Stephen Smith, M.D. from Dr. Smith's ECG Blog has stated that he has only seen one or two LAD occlusions in his entire career that met the conventional LVH criteria in the right precordial leads! Why should this be?

He theorizes that perhaps acute STEMI attenuates the S-wave voltage in the right precordial leads in the setting of pre-existing LVH.

Interesting theory! 

Consider this ECG from the previous case of the 55 year old male with (possible) chest pain.

In this case the patient was cathed and ended up having a 100% chronic occlusion of the LAD. However, the T-waves do appear to be hyperacute in this ECG and there was a modest rise and fall of cardiac biomarkers.

We were unable to obtain an "old" ECG for comparison, but based on the appearance of lead V1 it certainly looks as if this ECG met the LVH criteria in the precordial leads prior to the development of pathological Q-waves in leads V2 and V3.

A "strain pattern" (evidenced by ST-depression and T-wave inversion) is still present in the high lateral leads (I and aVL).

Now let's get back to the case of the 57 year old female with shortness of breath and chest pressure.

Does it meet the voltage criteria for left ventricular hypertrophy?

Absolutely!

The S-wave depth measures 23 mm in lead V1 and 29 mm in lead V2! The R-wave amplitude measures 12 mm in lead V5 and 13 mm in lead V6. So, if we add the S-wave depth in lead V2 and the R-wave height in lead V6 we get 44 mm (cut-off is 35 mm) so this meets the most commonly used voltage criteria for LVH.

Here's how I'm measuring the S-waves (see comments).

Here's a close-up of the right precordials from another ECG that was submitted with the case study that I didn't publish earlier due to poor data quality in the limb leads. Here you can see the separation a little bit better.

Based on this I would expect a significant ST/T wave abnormality in the opposite direction! To me the most striking thing about this case is the absence of significant ST-elevation in leads V1 and V2.

Having said that, the ST-depression and T-wave inversion in leads with an upright QRS complex are almost certainly due to left ventricular hypertrophy.

8 Comments

  • Brandon O says:

    Tom, is this just a misread on my part due to the small resolution? I'm measuring the S in V1 at 44mm, about 7mm in V2, and just 1-2mm in V3.

  • Christopher says:

    Brandon, I calculate out the same as you. Using ESTES LVH criteria I get 6 points (>=5 diagnostic) due to >30mm S in V1 or V2 (+3) and secondary ST-T abnormalities with widened QRS/T angle (+3).
    Beyond that, the way the ST-T goes opposite the QRS and flips with the R-wave progression sort of sold me on "secondary ST-T abnormality" rather than "primary". Especially with the global nature.

  • Brandon – This is why (one presumes) the ZOLL machine "crops" the QRS complexes so that they don't run into one another. I prefer it when the machine does not crop the QRS complexes, but the measurements can become difficult. This problem could be solved by creating a user interface that allows the paramedic to easily print out individual leads in diagnostic quality. At any rate, I did not measure the QRS complexes the way that you did. I created an image that shows where I think the QRS complexes begin and end. Thanks, Tom

  • Christopher says:

    Tom, perhaps Zoll could improve the cropping situation by placing a crop marker of some kind when it does that. They could then include in the interpretive statements: V1 S-WAVE CROPPED, TOTAL AMPLITUDE -4.4 mV

  • Good point! Leave it to a computer programmer! :)

  • Brandon O. says:

    Tom, I see your version now. This is like one of those trick images that changes from a vase to a couple of faces when you blink. Probably no settling it without a much larger scan.

    Hypothetically if it were all in V1, do you know of any electrical pathology that would produce such a large voltage difference between adjacent leads?

  • Brandon – I just added another image showing V1-V3 in higher resolution. I’m not smart enough to answer your question about pathologies that could lead that that large of a voltage difference in a contiguous precordial lead, but I’m certainly not saying it’s impossible!

  • Brandon O says:

    You win — that image cleared it up. Very sneaky tracing though!

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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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