CME INDIA Case Presentation by Dr Narendra Kumar, MD, Godda.

CME INDIA CASE: 69-year male, diabetic and hypertensive, was under a neurophysician for CVA-for last one year, developed dyspnea since last evening, approximately 24 hours. BP-80/60mm of Hg., no History of pain chest or perspiration. Troponin: Strongly positive. Gives no history of fever but temp. 98.8(Axilla). Chest x ray could not be done, as I have already referred the patient to higher centre after initial treatment.

Pulmonary Embolism or LMCA disease case ECG

What to think about this ECG?

CME INDIA Discussion:

Dr H K Jha, MD, Ranchi: Complete RBBB with LAHB

– Sinus Tachycardia

-Tall R wave in v 1 v2 and v3 with horizontal ST depression  from v 1 to v 6 with  maximum ST  depression in v 3 . But Isolated posterior MI is rare usually associated with Inferior wall,MI .

Three are doubtful ST elevation in lead III and aVF with rS pattern with S wave of lead lll is larger than s wave of lead 2

ST ELEVATION of lead lll > is more than avF and lead 2. 

– Horizontal ST depression in lead I and avL could be reciprocal changes.

– Required v7 to. 9 for confirmation.

TROP T positive, could be in acute MI or acute pulmonary embolism.

Patient having Dyspnea. With very tall r wave in lead in v1 (RBBB) with t inversion could be strain pattern of acute RV dilatation of acute P E.

– ST depression in chest leads with lead 1 and avL with ST elevation in aVR??

– could be subendocardial ischemia.

Required CT chest and lead v7 to v9 and D dimer.

My D/ D

(1) Inferior wall MI with post MI

(2) Acute pulmonary embolism

(3) Subendocardial ischemia

Tall R wave with tall upright T wave in v 2 and v3 with horizontal ST depression max in lead v3

But Left axis deviation: On the basis of S T elevation in aVR with ST depression in multiple leads – S T elevation in aVR>V1 – could be TVD or lt main?

Dr DP Khaitan, Gaya:  Agreed two groups of findings:

  • (1) RBBB +LAFB with ST elevation over aVR
  • (2) ST depression over leads aVL,1 + precordial leads

All the findings are well described by Dr Jha

RBB plus Left anterior fascicle both are supplied by LAD

I think all these facts are to be interpreted in the term of which coronary artery involved .

Yes, we should think in this direction…

There is an ECG dictum that if there exits such situation, there is the possibility of LMCA involvement or TVD…I do agree .

Also, Acute pulmonary embolism.should be excluded as well

Sometimes diffuse subendocardial ischaemia may occur in association with acute pulmonary embolism.

CME INDIA Learning Points:

(Input by Dr Satish Kumar, HOD, Dept of Cardiology, Bokaro General Hospital, Bokaro)

  • Very valid points raised by Dr. Khaitan.
  • Considering ST Elevation in aVR with Flat ST depression in Precordial leads in absence of tachyarrhythmia denotes a global subendocardial ischaemia. This makes a very strong point in favour of “LMCA Equivalent” ACS, further supported by appearance of ‘presumably new’ RBBB. [The ‘LMCA Equivalent stenosis’ obviously includes possibility of critical Proximal LAD or TVD as D/D.]
  • An urgently performed bed-side Echo in such situation is invaluable as it would clarify the situation by excluding other possibilities like Acute Pulmonary Embolism etc.
  • The Q waves in Inferior leads are most likely due to an old Inferior Wall MI.

The report of Coronary Cath must be shared