EKG of the Week 2017-5-28

This EKG comes courtesy of Dr. Khodorkovsky.

An 87 year old male with a history of HTN presents to the ED for chest pain and shortness of breath which began the night before. He vomited this morning.

V/S: Pulse 102, Respirations 16, BP 86/52.

He is ill appearing on exam.
His EKG is below.

1.       What does the EKG demonstrate?

2.       What is the diagnosis?

3.       How would you manage this patient?

ANSWER:

The EKG shows sinus tachycardia with an anterolateral ST elevation MI.

The diagnosis is Cardiogenic shock

Cardiogenic shock is managed with aspirin, anticoagulation, vasopressors, and urgent cath.

 

The EKG demonstrates ST elevations in leads V1-V6, I and aVL with reciprocal depressions in leads II, III and aVF. This is consistent with an anterolateral STEMI. It usually suggests a proximal LAD occlusion.

The patient’s clinical condition (acute MI with tachycardia and hypotension) is consistent with cardiogenic shock. Cardiogenic shock is a state of heart failure that results in inadequate cardiac output, hypoperfusion, and end-organ dysfunction. The most common cause is LV dysfunction from an acute MI. It carries a very high mortality rate (50-80%).

The acute MI should be managed as all other MI’s with aspirin and anticoagulation. To manage the shock, Dobutamine can increase cardiac output but it causes hypotension. Norepinephrine is the preferred first-line adrenergic agent.

Cardiac cath with PCI is the treatment of choice.

Our patient went to the cath lab and was found to have a 100% occlusion of the proximal left main, as well as 70% occlusion of the proximal RCA. His ejection fraction was 10%. An intra-aortic balloon pump was placed. He was treated with vasopressors. Unfortunately he expired the following day.

 

Reference: Moskovitz et al. Cardiogenic Shock. Emerg Med Clin N Am 33 (2015) 645–652.