EKG of the Week 2019 5-19

This EKG comes courtesy of Dr. Joseph Basile.

A 50 y/o male police officer complains of “agita”. He reports heartburn sensation on and off x 3 days. He had another episode today. He has been taking Tums and Nexium which have been relieving his symptoms.

His EKG is below.

2019 5-19.jpg

1.      What does the EKG demonstrate?

2.      How would you manage this patient?


The EKG demonstrates ventricular bigeminy with an evolving anterior wall STEMI.

The patient should be managed as a STEMI with antiplatelet agents and emergent revascularization.


The EKG shows a sinus rhythm with ventricular bigeminy (every second beat is a PVC). When PVC’s are present on an EKG, it can make the diagnosis of MI difficult because the PVC’s must be ignored and the native beats must be examined for signs of MI.

On this EKG, the native beats in leads V1-V3 show ST elevations with Q waves. There are also mild ST elevations in the native beats of leads V4-V6, I and aVL. There are reciprocal ST depressions in the native beats in leads II, III and aVF. (See arrows below.)

2019 5-19 answer.jpg

When faced with an EKG with PVC’s or PAC’s, look at only the native beats to determine the rhythm and to see if there are signs of MI.

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