EKG of the Week 2016 11-27

A 74 year old male with a history of diabetes complains of chest pain and SOB x several hours. He is still having pain.

V/S: P – 90, R – 20, BP 140/80.

His EKG is below.

1.       What does the EKG demonstrate?

2.       What is the correct management of this patient?

 

ANSWER:

The EKG demonstrates an evolving anterolateral MI.

The patient should be managed emergently for an STEMI with antiplatelets, anticoagulation and emergent reperfusion therapy (PCI or thrombolytics).

 

The EKG demonstrates ST elevations in leads V1-V5, I and aVL. This is consistent with an anterolateral acute MI. There are also Q waves in those same leads. Q waves typically represent an old MI or completed MI. How can you have an acute MI and a completed MI in the same leads?

The answer is this is called an “evolving MI”. This means the MI has been ongoing for several hours. As a result, some of the myocardium is already dead. This is represented by the Q waves. However, there is still myocardium which is at risk and is salvageable by reperfusion therapy. So, PCI or thrombolysis is still indicated.

Whenever you see both ST elevations and Q waves in the same leads, that represents an evolving MI. If the patient had waited several more hours without obtaining treatment, the ST segments would return to baseline and the Q waves would deepen. So, the EKG would show deeper Q waves in those leads with only minimal (or no) ST elevation. That would represent a completed MI. At that stage, the myocardium has already died and thrombolysis is no longer indicated. The EKG will likely stay this way for the rest of the patient's life. However, if there are still ST elevations appreciated, that suggests there is still myocardium at risk which should be treated with reperfusion therapy.