EKG of the Week 2019 8-25

This EKG comes courtesy of Dr. Conor Russell.

 

58 year old male with PMHx of HTN presented to the ED for diffuse chest pain, 8/10, associated with nausea. Onset 20 minutes prior to arrival while he was mowing the lawn. The patient was given 2 sublingual nitro’s by EMS with no symptomatic relief.

 VS T 98.4, HR 70, BP 149/92, RR 20, SpO2 99%

 Patient was ill appearing, diaphoretic and clutching his chest. 

 

His EKG is below.

2019 8-25.jpg

1.     What does the EKG demonstrate?

2.     How would you manage this patient?

ANSWER:

The EKG shows slight ST depressions with tall T waves in the anterior leads. This is known as deWinter’s T waves.

 This pattern should be recognized as a STEMI equivalent and the patient should have urgent reperfusion.

 

Hyperacute T waves have long been described as an early finding in acute MI’s. This finding typically evolves into ST elevations.

In 2008 deWinter described an EKG pattern similar to hyperacute T waves that often persisted and never evolved into frank ST elevations. The pattern was noted in 2% of patients with anterior wall MI’s who were found to have 100% LAD occlusions on cath.  The EKG pattern they noticed was, “1-3 mm upsloping ST segment depression at the J point in leads V1-V6 that continues into tall positive symmetrical T waves” (de Winter et al. N Engl J Med 2008;359:2071). There was often associated 1-2mm ST elevations in lead aVR. They recommend that, “Ambulance staff, emergency physicians, cardiologists and other caregivers involved in STEMI networks should familiarize themselves with these sometimes subtle ECG changes. …practitioners should not miss the important finding of the ECG pattern described above to avoid potential delay in treatment” (de Winter et al. Journal of Electrocardiology. 2016; 49:76–80).

 Our patient’s EKG demonstrates slight ST depressions in leads V2-V6 with tall T waves in these leads. (There are also slight ST depressions in leads II, III and aVF). There is slight ST elevation in lead aVR. At the insistence of the brand new ED attending Dr. Russell, the patient was taken to the cath lab and found to have a 100% proximal LAD occlusion. Stents were placed.

Hyperacute T waves from acute ischemia can be difficult to distinguish from peaked T waves seen in hyperkalemia. One article suggests that hyperacute T waves are “asymmetric with a broad base” (Brady et al. J Accid Emerg Med 2000;17:40–45). However, peaked T waves in hyperkalemia are, “tall, narrow, and peaked with a prominent or sharp apex, and are symmetrical” (Brady et al. J Accid Emerg Med 2000;17:40–45).

 

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.

2017 11-19.jpg

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.