ECG of the Week – 15th January 2018 – Interpretation

The following ECG is from a 63 yr old female who presented with a 3 day history of colicky right upper quadrant abdominal pain. She is normally fit and well and has no prior past medical history.


Click to enlarge

Rate:
  • 78 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~160ms)
  • QRS - Normal (80ms)
Additional:
  • Subtle ST elevation leads II, III, aVF, V3-6
  • T wave inversion leads II, III, aVF, V3-6
  • Low voltage P wave with notching in lead II

Interpretation:

  • Diffuse ST and T wave changes

DDx includes:

  • ACS
  • Demand ischaemia secondary to sepsis
  • Cardiomyopathy - acute vs chronic
  • Electrolyte abnormality / Acid-base disturbance

This patient had no history of chest pain, nil pre-existing medical condition and was not significantly unwell from her assumed cholecystitis. Vital signs and electrolytes were normal.
She was admitted under the cardiology team for further investigation of ECG abnormalities with surgical consultation for management of cholecystitis.
The patient had raised cardiac biomarkers and underwent angiography.
The angiogram showed no coronary vessel disease but Takotsubo pattern cardiomyopathy, EF 35-40%. The patient was commenced on beta-blocker, ACE and diuretic therapy and will undergo an elective cholecystectomy once normal cardiac function returns on follow-up echo.

Check out some great cases from Dr Smith's ECG blog on Takotsubo here:
Other resources
References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

ECG of the Week – 8th January 2018 – Interpretation

The following ECG is from a 31 yr old female who is 5 days post-partum she was brought to the Emergency Department following a episode of collapse. On arrival to the Emergency Department she was hypotensive ( Systolic BP ~80 mmHg) with an altered conscious level complaining of chest pain and headache.



Click to enlarge
Rate:
  • 60 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal
  • QRS - Normal
Additional:

  • ST Elevation in leads aVR & aVL (<1mm font="">
  • Upsloping ST depression in leads V2-6 
    • Maximal in leads V3-4
  • Flat ST depression in the inferior leads
  • Prominent T waves in leads V2-4 

Interpretation:

  • Features consistent with a De Winter's pattern
    • Suggesting potential LAD pathology
    • DDx Demand ischaemia / perfusion mismatch

Given the patients age and medical history broader differentials for shock and ischaemic ECG features would be:

  • PE
  • Sepsis
  • Endocrine - Sheehan's Syndrome


What happened ?



The patient was initially treated with iv fluid, analgesia and broad spectrum iv antibiotics ( as initial broad DDx included sepsis). Following review of the initial ECG urgent cardiology input was obtained and an emergent CTPA was performed to exclude PE as a potential cause. On return from a negative CTPA the patient complained of further chest pain, repeat ECG below:
Click to enlarge
Clear anterolateral ST elevation and inferior ST depression. The patient was transferred for urgent angiography which showed a 90% mid LAD lesion treated with bioresorbable stent. Subsequent CTPA revealed a coronary artery dissection as the cause for the acute LAD lesion.

Coronary Artery Dissection
This is a rare phenomena occurring in ~4% of all acute MI's. Approximately 90% of cases occur in females and it accounts for 1/4 of MI's in the under 50 yr old age group. Recurrence rate is between 13-18%.

There are multiple risk factors including:

  • Fibromuscular dysplasia
  • Pregnancy
  • Connective tissue disorders
  • Systemic inflammatory conditions
  • Intense exercise
  • Intense emotional stress
  • Labour and delivery
  • Valsalva-like events
  • Sympathomimetic use

References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.