EKG of the Week

A 77 y/o male with history of hypothyroidism and BPH c/o chest pain 2 days ago while at rest.  He then went on a two mile walk and had no symptoms.  Now he has mild epigastric discomfort.

  1. What does the EKG demonstrate?
  2. How would you manage this patient?

A1.  The EKG demonstrates a RBBB.  This explains the T wave inversions in leads V1-V3. However there are also T wave inversions in leads V4-V6, II, III, and aVF.  This represents inferolateral ischemia.

A2.  This patient should be treated for ACS. His initial troponin was 9.

The criteria for a RBBB are:

  • Wide QRS (>0.12  seconds or 3 little boxes)
  • RSR’ V1, V2, V3
  • Secondary ST/T changes V1-V3
  • Deep terminal S waves V5, V6, I, aVL

The T wave inversions in V1-V3 on this EKG are part of the RBBB pattern. Thus, they do not represent ischemia. However, the T wave inversions in the inferolateral leads are not expected in a RBBB. They represent inferolateral ischemia. Patients presenting to the ED with T wave inversions are significantly more likely to have an adverse outcome within 30 days. Adverse outcomes in this study included death, acute myocardial infarction, revascularization, coronary stenosis greater than 50%, or a stress test with reversible ischemia.

(Lin et al. Predictive Value of T-wave Abnormalities at the Time of Emergency Department Presentation in Patients with Potential Acute Coronary Syndromes. Acad Emerg Med 2008; 15:537–543)
Our patient presented with a NSTEMI manifesting on EKG as T wave inversions. His initial troponin was 9 and then downtrended. He likely infarcted two days prior to presentation. Cardiac cath showed a 99% stenosis of the mid LAD. He was discharged home 3 days later.