EKG of the Week 2017 11-19

This EKG comes courtesy of Dr. Elias Youssef.

A 51 year old male with no past medical history complains of chest pain. The pain woke him from sleep. It is right sided, described as sharp. It radiates to the mid back. It is associated with shortness of breath and the pain is worse when he takes a deep breath. There is no nausea or vomiting.

The EKG is below.

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1.    What does the EKG demonstrate?

2.    How would you manage this patient?

 

ANSWER:

The EKG shows hyperacute T waves in leads V2-V4.

Hyperacute T waves can be an early sign of an STEMI. Serial EKG’s should be performed as the ST elevations may develop. Even if the ST elevations do not develop, urgent cardiology consultation should be sought as these patients may have a proximal LAD occlusion and may need urgent PCI.

 

The EKG demonstrates tall symmetric T waves in leads V2-V4. This can be an early sign of a STEMI. Serial EKG’s may evolve and start to show ST elevations in those same leads.

However, in some patients this T wave pattern persists and ST elevations never develop. Nevertheless these patients are found at cath to have proximal LAD occlusions. These are referred to as deWinter’s T waves. The EKG shows 1- to 3-mm upsloping ST-segment depression at the J point in leads V1 to V6 that continue into tall, positive symmetrical T waves. In most patients in the deWinter article there was a 1- to 2-mm ST-elevation in lead aVR.

It is difficult to differentiate these T waves from the peaked T wave seen in hyperkalemia. When you see this T wave pattern, both hyperkalemia and acute coronary syndrome should be considered in the differential.

Our patient went to the cath lab and was found to have a 100% proximal LAD occlusion. He had a stent placed and did well.

REFERENCE: de Winter et al. A New ECG Sign of Proximal LAD Occlusion. N Engl J Med 2008:359;19.