EKG of the Week 7-16

This EKG comes courtesy of Dr. Ann Giovanni.

A 70 year old female with a history of CAD with a previous stent, hypertension, and high cholesterol presented to the ED complaining of pressure like chest pain which developed while walking in the grocery store. She has associated nausea and vomiting. 

V/S: BP 160/90, Pulse 72, Respirations 18, O2 sat 100% on room air. 

Her EKG is below.

1.       What does the EKG demonstrate?

2.       What is the significance of these findings?

Answer:

The EKG shows diffuse ST depressions in leads V2-V6, I and aVL as well as II, III and aVF. There are ST elevations in leads V1 and aVR.

It suggests an occlusion of the Left Main Coronary Artery.

 

The EKG shows diffuse ST depressions in leads V2-V6, I and aVL as well as II, III and aVF. There are ST elevations in leads V1 and aVR.

We know that when there are both ST depressions and ST elevations on the same EKG, the pathology is where the elevations are. The depressions are only a reciprocal change. So, where is this MI located?

This pattern of diffuse ST depressions with ST elevations in leads aVR and V1 suggest an occlusion of the left main coronary artery (or triple vessel coronary disease). The pattern predicts left main occlusion with 80% accuracy. We don’t often see patients with left main occlusion because they typically present as a v-fib arrest. However, when we do see these patients they are often quite sick and may be in cardiogenic shock.

This patient went to cath and was found to have an occlusion of the distal left main coronary artery. He had CABG surgery and did well.

 

 

Aygul et al. Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction. J Electrocardiology 2008;335-41.

Vorobiof et al, Lead aVR: Dead or Simply Forgotten? JACC 2011;187-90.