the case.
a 42 year old male presents via ambulance with chest pain following an motor vehicle accident.
He reports being in a moderate speed MVA approximately 90 minutes ago where he was side-swiped, but bought his car to a controlled stop. What followed can only be classified as ‘road-rage’. People were assaulted (not the patient) and there was significant emotional tension.
His pain started shortly after this…
This is his ECG…
- Rate:
- ~63 bpm.
- Rhythm:
- Sinus. Regular.
- Axis:
- + 27* (normal)
- Intervals:
- PR ~ 200 msec
- QRS ~ 70 msec
- QTc ~ 420 msec (Bazett)
- Segments:
- ST elevation (concave up) – leads I & aVL (2mm), V5-6 (1mm) & V4 (1/2 mm).
- ST depression – III, aVF, aVR & V1.
- Others:
- Large, bulky, asymmetric T-waves (V3, +/- V2 & 4) w/ straightening of ST-segment ?Hyperacute T-waves.
Interpretation.
High-lateral STEMI which meets reperfusion criteria.
So, you go into his history in more detail & it turns out he carries a few risk factors.
PMHx.
– Hypertension (on ACEi)
– Hyperlipidaemia (not treated…)
– Strong FHx of ischaemic heart disease (older brother, father, uncles x2).
He consistently reassures you that the accident “was nothing at all” and he didn’t sustain any injuries…
Would you thrombolyse this guy if PCI was NOT available ??
- No absolute contraindications for thrombolysis.
- However, given the recent MVA (a relative contraindication), is a normal examination & a patient who’s reassuring you enough to give the drug…
Here’s a refresher on Thrombolytic Contraindications…
Fortunately for us (and him) our Cath-lab was available & off he went for PCI 30 minutes after arriving to ED….
- Angiogram – 100% proximal first-diagonal occlusion.
- Successful angioplasty…
Take Home Point.
“Chest pain following an MVA” was an immediate distraction in this case. If we are not careful we can, at times, be automatically taken down the completely wrong path.
It is easy to get distracted by the immediate events leading to a patients’ hospital presentation. Just last week I saw a patient with “delayed epigastric pain post-MVA” where her chest did hit the steering-wheel; Final diagnosis = acute cholecystitis.
We owe it to ourselves (& our patients) to pause, just for a moment, & ensure that all the pieces to their puzzle are coming together….
Mohammed Abdelghani says
November 2, 2013 at 7:31 pmST elevation in 1 and aVL with reciprocal ST depression inferiorly.. Dx Acute high lateral MI.
Vince D says
November 3, 2013 at 4:06 amAwesome case! I wouldn’t even put a question mark when mentioning the hyperacute acute T-wave in V3; it’s markedly abnormal and actually meets “de Winter morphology,” though we’re looking at something a bit different.
I also love this case because it emphasizes the importance of knowing your coronary artery distributions. Some folks might argue that the injury pattern is non-anatomic and therefore likely the result of contusion, but those in the know will quickly pick up the classic first-diagonal occlusion pattern (I, aVL, V2, V3). In a trauma setting it could still be something weird like coronary artery dissection, but seeing this distribution of injury on the ECG certainly raises the likelihood of occlusion and decreases the chances of contusion. Very cool presentation.
Rohan Church says
November 5, 2013 at 3:22 pmST-T changes are definitely pretty ischaemic looking.
From the case notes, is there a suggestion that this could be tako-tsubo with spasm of the first diagonal?
Ken Grauer, MD says
November 8, 2013 at 8:47 amNice case. As stated by Chris – it is easy to be distracted by other happenings in the history (ie, a MVA … ). There is NO mistaking the marked ST elevation in the high lateral leads (I, aVL). But in addition – there are hyperactue T waves in V2-thru-V5.
Lead aVL is a KEY lead in assessing patients with chest pain for acute stemi. I’ve summarized the findings in a study by Birnbaum et al on my web page on Acute MI Localization. GO TO: https://www.kg-ekgpress.com/ecg_-_coronary_anatomy-mi_localization/#LAD%20OCCLUSION%20-%20SubHeading – Acute occlusion of the 1st Diagonal is suggested when there is ST elevation in lead aVL and in lead V2 – but not in other precordial leads.
This case is similar, though not totally fitting to that in that the slight ST depression in V3 with very tall (considering the small QRS in V3) T wave looks like a DeWinter T wave – which usually suggests a proximal LAD occlusion. So I’d be torn on ECG between whether this is more suggestive of a 1st Diagonal vs proximal LAD occlusion. That said – the KEY point (as per Chris) is that acute STEMI in need of reperfusion is needed, despite the “distractors”. NICE Case!