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.
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