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.
- What does the EKG demonstrate?
- 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.