Case 91

1
Case 9-1

• This 48-year-old obese woman with diabetes
  mellitus (DM) and hyperlipidemia presented with
  atypical CP.

2
Case 9-1
3
Case 9-1

• ECG 9-1A (Type 3)
• At 0321
• Nonspecific, poor R-wave progression. The
  patients CP continued. She was admitted to the
  CCU before serial ECGs were recorded.

4
Case 9-1
5
Case 9-1

• ECG 9-1B (Type 1b)
• At 0552
• ST elevation V1-V3 (1 mm at the J point but 2 mm
  at 80 ms after the J point) and hyperacute T
  waves V2-V5, definitely new. This ECG alone is
  diagnostic of AMI but is especially remarkable
  when compared with ECG 9-1a.

6
Case 9-1

• Although the computer printout read consider
  anterior infarct, clinicians interpreted ECG
  9-1b as normal. Anterior AMI was obvious on a
  follow-up ECG, and a distal 100 LAD occlusion
  was opened with angioplasty at 1200 hours. Total
  CK peaked 20 hours after presentation at 700 IU/L
  with cTnI of 16.8 ng/mL.

7
Case 9-1

• Immediate angiography PCI is indicated.

8
Case 9-2

• This 62-year-old non-English-speaking woman
  presented with CP.

9
Case 9-2
10
Case 9-2

• ECG 9-2A (Type 4)
• This is a previous ECG of leads V1-V3 only this
  was available but not sought for comparison.
• There is NO ST elevation.

11
Case 9-2
12
Case 9-2

• ECG 9-2B (Type 1b, but Type 1a when compared with
  previous ECG)
• ST elevation V1-V3 (2 mm at the J point but 4 mm
  at 80 ms after the J point), is diagnostic of
  anterior AMI by itself, but especially when
  compared with ECG 9-2A. Due to the elevated J
  point and upward concavity, clinicians
  misdiagnosed this as early repolarization.

13
Case 9-2

• The patient was admitted to the CCU. A repeat ECG
  showed increased ST elevation. After
  thrombolysis, ST segments completely normalized
  to baseline. Subsequent reocclusion was treated
  with LAD angioplasty. Convalescent EF was 50.

14
Case 9-2

• Reperfusion therapy was delayed 90 minutes
  because of misdiagnosis as early repolarization.
  Comparison ECG 9-3A wound have made the diagnosis
  obvious.

15
Case 9-3

• This 41-year-old man with risk factors for AMI
  presented with typical CP.

16
Case 9-3
17
Case 9-3

• ECG 9-3 (Type 1b)
• ST elevation almost 1 mm, II, III very large T
  waves slight ST elevation with low QRS voltages
  aVF reciprocal depression aVL. This ECG is
  diagnostic of inferior AMI.
• ST depression minimal, V2-V4, is suspicious for
  posterior AMI.

18
Case 9-3

• The computer algorithm and clinicians missed this
  AMI. A repeat ECG 80 minutes later showed more
  pronounced changes and tPA was given.
  Echocardiography revealed an inferoposterior WMA
  but good LV function. An ECG the next day
  revealed inferior QS waves. Total CK peaked at
  1,363 IU/L. Angioplasty opened a tight
  mid-circumflex stenosis.

19
Case 9-3

• Reperfusion therapy was delayed due to failure to
  diagnose a subtle inferior posterior AMI.

20
Case 9-4

• This 65-year-old woman presented with 2 hours of
  typical CP.

21
Case 9-4
22
Case 9-4

• ECG 9-4A (Type 1c)
• Left anterior fascicular block (LAFB) (see
  Chapter 17).
• ST elevation subtle, II, III, aVF, I, V5-V6
  reciprocal depression subtle, aVL, V1-V3. This
  ECG is suspicious for a subtle infero-lateral-post
  erior AMI.

23
Case 9-4
24
Case 9-4

• ECG 9-4B (Type 3)
• A previous ECG was obtained.
• LAFB and ST segments are isoelectric at
  baseline. Comparison with this ECG confirms that
  Ecg 9-4a is diagnostic of infero-lateral
  posterior AMI.

25
Case 9-4

• Clinicans did not recognize this AMI. An ECG
  recorded 20 minutes later showed 1-mm ST
  elevation in II, III, aVF with increased
  reciprocal depression, but it was overlooked
  again. At 14 hours after pain onset, cTnI peaked
  at 63 ng/mL and total CK at 1,150 IU/L. Although
  indicated, reperfusion therapy was not
  administered. Angiography 36 hours after
  presentation showed that the circumflex consisted
  predominantly of a large second obtuse marginal,
  which was occluded with thrombus. It could not be
  opened with angioplasty and thus was treated with
  a GP Iib-IIIa inhibitor.

26
Case 9-4

• Clinicians missed this infero-lateral posterior
  AMI despite typical symptoms, comparison with an
  old ECG, and a follow-up ECG.

27
Case 9-5

• This 81-year-old man presented with less than 1
  hour of typical CP.

28
Case 9-5
29
Case 9-5

• ECG 9-5A (Type 1c)
• LAFB right axis deviation and large S waves II,
  III, aVF.
• Notice the minimally elevated J point V1-V3
  this could be normal.
• Large T wave V2, suspicious for possible being
  hyperacute T wave V1 is larger than in V6,
  favoring AMI over early repolarization and
  septal Q wave V2, is also suspicious.

30
Case 9-5
31
Case 9-5

• ECG 9-5B (Type 3)
• A previous ECG was obtained V1-V6 only shown.
• ST segments are isoelectrc at baseline.
  Comparison with this previous ECG enabled
  clinicians to determine that ECG 9-5A was
  diagnostic of anterior AMI.

32
Case 9-5

• Thrombolytics were administered. An ECG recoded
  after reperfusion therapy was identical to ECG
  9-5B (the baseline ECG), with no Q waves, and a
  normalized T wave in V2. Troponin (cTnI) and
  total CK were confirmatory but minimally
  elevated. Convalescent echocardiography revealed
  no WMA and normal LV function.

33
Case 9-5

• So little myocardium was lost in this rapidly
  treated AMI that there were no lingering
  repolarization abnormalities, such as T-wave
  inversion. Timely diagnosis and treatment in this
  case were facilitated by recognition of subtle
  signs of AMI and prompt comparison with a
  previous ECG.

34
Case 9-6

• This 42-year-old man presented with 45 minutes of
  CP.

35
Case 9-6
36
Case 9-6

• ECG 9-6A (Type2)
• At 1040, 40 minutes after arrival
• Disproportionately large T waves V2-V4 and ST
  depression V2-V6 are suspicious for anterior
  AMI. Frequent serial ECGs are indicated.

37
Case 9-6

• Clinicians did not suspect AMI and did not record
  frequent serial ECGs. The patient was admitted to
  the CCU. Although tPA was ultimately administered
  5.25 hours after pain onset, the ECG that
  prompted thrombolytic therapy was not found.

38
Case 9-6
39
Case 9-6

• ECG 9-6B
• The patient ruled in for a large anterior MI with
  deep Q waves, V1-V5. Echocardiography revealed a
  new anteroseptal and apical WMA.

40
Case 9-6

• Hyperacute T waves may be preceded by a depressed
  take-off of the ST segment (see also ECG 9-7A).
  Diagnosis and thrombolysis of this extensive
  anterior AMI were delayed by hours because the
  significance of the ST segments and T waves was
  not appreciated. Earlier repeaat ECGs are
  indicated.

41
Case 9-7

• This 56-year-old man presented with CP of short
  duration.

42
Case 9-7
43
Case 9-7

• ECG 9-7A (Type 1b)
• ST elevation minimal, V1 only and profound
  hyperacute T waves V2-V3 are diagnostic of
  anterior AMI.

44
Case 9-7
45
Case 9-7

• ECG 9-7B (Type 1a)
• Twelve minutes later
• ST elevation V2-V4 subtle but diagnostic of
  anterior AMI.

46
Case 9-7

• An ECG 27 minutes later had 4 mm of anterior ST
  elevation. Thrombolysis resulted in successful
  reperfusion, with a small elevation of CK-MB and
  no complications.

47
Case 9-7

• Clinicianss suspicion of AMI and confirmation
  with a serial ECG enabled timely thrombolysis and
  minimization of myocardial damage.

48
Case 9-8

• This 36-year-old diabetic man presented with 45
  minutes of CP.

49
Case 9-8
50
Case 9-8

• ECG 9-8A (Type 1b)
• At 1446, is half standard calibration in the
  precordial leads (0.1 mV0.5 mm amplitude, versus
  full standard calibration of 0.1 mV1.0 mm). See
  step-down box at far right.
• Q waves and high voltage V1-V3, probably due to
  LVH, since there is no evidence of previous MI.
• ST (J point) elevation 1 to 2 mm, V2-V3, and
  minimal in aVL hyperacute T waves I, aVL,
  V2-V4. Although this ECG might be misinterpreted
  as LVH with or with out old anterior MI, it is
  diagnostic of anterior AMI. A serial ECG at
  1527, at halt standard calibration, was
  identical to ECG 9-8A.

51
Case 9-8
52
Case 9-8

• ECG 9-8B (Type 1a)
• Also at 1527, is full standard calibration.
• Massively hyperacute T waves V2-V5. These were
  present all along, but obscured by the half
  standard calibration.

53
Case 9-8

• The patient received thrombolytics total CK
  peaked 7 hours later at 4,000 IU/L.

54
Case 9-8

• Failure to recognize hyperacute T waves resulted
  in delayed thrombolysis.

55
Case 9-9

• This 65-year-old man complained of 1 hour of
  typical CP.

56
Case 9-9
57
Case 9-9

• ECG 9-9A (Type 4)
• This is a baseline normal ECG from 4 days earlier.

58
Case 9-9
59
Case 9-9

• ECG 9-9B (Type 1a)
• T waves large, V2-V4. A potassium level of 4.5
  mEq/L (normal) indicates that these are not due
  to hyperkalemia. Therefore this ECG is diagnostic
  of anterior AMI and reperfusion therapy is
  indicated.

60
Case 9-9

• Clinicians missed this AMI, but fortunately the
  artery spontaneously reperfused. An ECG 6 hours
  after ECG 9-9B was normal. A second serial ECG
  recorded 9 hours after ECG 9-9B showed anterior
  terminal T wave inversion, nearly identical to
  Fig. 8-6 (Wellens syndrome). Angioplasty opened
  a 99 LAD stenosis the next day.

61
Case 9-9

• Failure to recognize hyperacute T wave could have
  resulted in complete anterior wall necrosis had
  there not been spontaneous reperfusion.

62
Case 10-1

• Unknown