EKG of the Week 2-18 5-13

This EKG comes courtesy of Dr. Shant  Broukian.

59 year old male with a history of hypertension and high cholesterol, presented to an urgent care center complaining of chest pain. The pain began 48 hours prior as a substernal burning sensation radiating to bilateral arms occurring at rest. The day before presentation the pain recurred with minimal exertion.
Family history significant for father who died at age 58 from an MI. 

The EKG is below.

1.    What does the EKG demonstrate?

2.    What is the significance of these findings?

3.    How would you manage this patient?

ANSWER:

The EKG shows biphasic T waves in leads V1-V3 extending out to V6.

This is known as Wellen’s sign. It suggests a critical proximal LAD occlusion.

The patient should receive aspirin and other anti-platelet therapy (clopidogrel or ticagrelor). He should be sent to an Emergency Department with emergent cardiology consult for possible cath.

 

The EKG shows a sinus rhythm with biphasic T waves in leads V1-V3 extending out to V6. This pattern is known as Wellen’s sign. It is suggestive of a proximal LAD occlusion and a 75% risk of anterior wall MI. Wellen’s sign consists of a minimally elevated takeoff of the ST segment from the QRS complex, a concave or straight ST segment and a symmetrically inverted T wave in leads V1-V3. Some patients can have findings extend out to lead V4 or even V5 and V6. (de Zwaan et al. Characteristic Electrocardiographic Pattern Indicating a Critical Stenosis High in LAD in Patients Admitted Because of Impending Myocardial Infarction. Am Heart J 1982;103:730-6.)

Our patient was transferred to the ED. His initial troponin was 1.63. Cardiac cath showed a 99% occlusion of the proximal LAD.

Our patient reported pain radiating down both arms. Classically, MI’s are described as presenting with chest pressure radiating down the left arm. However, the literature suggests that pain radiating down the right arm is equally suggestive of acute coronary syndrome as the left arm. Radiation to both arms is the most predictive. (Fanaroff et al. Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2015 Nov 10;314(18):1955-65.)