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45 year old male

by on October 13, 2011

This is a series of 12 lead EKG’s on a 45 year old male patient. Patient complained of substernal chest pain for 2 hours prior to calling EMS. He stated history of High blood pressure, End stage Renal disease but not on dialysis, and high Cholesterol.

Patient was given 324mg Aspirin and NTG spray SL x 2 with pain 7/10 down to 2/10


Blood pressure

I do not know the outcome of this patient or have any further updates.

First EKG
HR 71
PR 139
QRS 92
QTC 423

14 minutes later another 12 lead obtained
PR —
QRS 140
QTC 553

Just 3 minutes later another EKG change
HR 80
PR 166
QRS 80
QTC 419

what do you think?

From → Case File, Education

  1. VinceD permalink

    1. Normal sinus rhythm with a rate of ~75 bpm, a QRS axis ~45 degrees, and most importantly, what appears to be 0.5mm of ST-elevation in aVL (and maybe I) with preservation of the J-wave along with 0.5mm of ST-depression in III and aVF. This may or may not be normal for the patient, but with the clinical scenario you have to have STEMI on your mind.
    2. Accelerated ventricular rhythm with signs of retrograde p-waves indicating V-A conduction. This may be a marker for reperfusion of the patient’s ischemia and lends more weight to the argument for something acute going on in the patient’s heart.
    3. Very similar tracing to #1, but of note, the ST-elevation in aVL appears to have resolved a bit. Also of note, the amplitude of the T-waves in the limb leads (except II) and V2 has decreased markedly from the initial 12-lead. Also, aVF is no longer biphasic. I’m unsure if this could be related to patient position, the slight increase in rate, or the fact that the QRS-axis is now closer to 35 degrees than 45, but it is definitely worth noting as it could also be another sign of ischemia resolving. While I would never call the T-waves in #1 “hyperacute,” maybe in comparison to #3 they’d be considered “acute.”

    At this point, if I were looking at these from the back of an ambulance instead of my computer, I highly doubt I would feel confident enough to call in a STEMI alert and drag in the cath team, and don’t know if I could even get away with it without the arbitrary 1mm of elevation in my region. Maybe this is something Dr. Smith would be comfortable calling since he loves cases like this, but neither myself, nor (I’m assuming) most of the emergency physicians in my region would probably go that far just yet. I would at least be calling ahead to the receiving facility (I really hope cath capable) and letting them know what I find so they’re prepared, but in my mind it’s a 50/50 shot whether all of these findings are actually acute or just normal for the patient.

    On the other hand, an accelerated ventricular rhythm IS highly associated with reperfused MI… I’m very sad this case doesn’t have any follow-up, but thanks for sharing and I look forward to reading what everyone else sees here.

  2. Ryan permalink

    Starts in a sinus rhythm with inverted T in lead III, biphasic T in AVF. ST in V2 and V3 slightly abnormal looking, but not quite elevation. Enough to peak an interest when combined with the complaint and HTN.

    Progresses to a junctional tach. Anterolateral elevation with reciprocal changes and change in axis. It returns back to the original rhythm, so the ischemia must be affecting those pacemaker sites. I would be anticipating a heart block or ventricular dysrhythmia to follow this. PCI is certainly indicated.

  3. Ryan permalink

    **Accelerated junctional. I don’t believe it’s ventricular because looking at the sample lead II, it isn’t wide enough and the slight S depression is probably a buried P wave. The width seen in the 12 lead is most likely abberant.

  4. The first ECG is concerning, especially with the ST-D in III/aVF and the Q in aVL (not sold on any appreciable ST-E). Whether the change is AIVR or Accelerated Junctional, I’m not a fan of the concordance in the lateral precordials.

    Another interesting aspect is the lessening ST-D between the first and last 12-Lead. Also the prolonging of the QTi and the better definition in the U-waves seen in the anterior precordials.

    STEMI? Not one I’d call in the field, but I’d be letting them know it’s a cardiac candidate.

  5. Taking another look at the axis and the morphology of the beats, I’m no longer thinking junctional. aVR is positive, 4th beat looks to be a fusion. Also RAD present, and it is almost a 90 degree axis. Right ventricular site going anterior to posterior (V1 is negative) maybe? LCX occlusion perhaps. Big fan of these strips.

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