Anterior wall myocardial infarction

A 42-years old male came in the emergency with chief complaints of acute onset retrosternal chest pain of 2 hours duration along with palpitation, perspiration,dizziness and dyspnoea. Patient was a known case of hypertension since last 5 years, chronic smoker, used to smoke around 2-3 packet of cigarettes  per day since last 20 years. During evaluation in the emergency patient blood pressure was 110/70 mmhg, pulse rate was 94 beats per minute. On examination of the chest patient bilateral normal vesicular sound heard and there were no added sound. Patient ECG done in the emergency is shown below

ECG 1

ECG is showing normal sinus rhythm at around 94 beats per minute, Left axis deviation, there is ST segment elevation seen in lead V1-V5, also mild ST segment elevation seen in lead V6, and also minimal ST elevation in lead 1, avL, there is ST segment depression seen in lead III, avF so the ECG of the patient is suggestive of extensive acute anterior wall myocardial infarction.

ECG 2 

Another ecg of the same patient is showing marked ST segment elevation in lead V1-V6, also very mild ST segment elevation also seen in lead I, avL, there are reciprocal changes in the form of ST segment depression seen in lead III, avF so the final diagnosis of the ECG is Acute ST elevation anterior wall myocardial infarction.

Patient was immediately started on injection streptokinase thrombolytic therapy. Patient ECG done 6 hours after thrombolysis is shown below.

  ECG 3

ECG is showing marked ST segment resolution in lead V1-V6 which is more than 50% suggestive of successful thrombolysis.

So the final diagnosis is Acute ST segment elevation anterior wall myocardial infarction with successful thrombolysis.


Thank you,
Dr Praveen Gupta

Anterior wall myocardial infarction

A 38- years old male came with history of acute retrosternal chest pain of 4 hours duration along with palpitation, perspiration and dyspnoea. Patient was a known case of Diabetes mellitus since last 6 months and was on oral medication. Patient was chronic smoker. ECG of the patient done in the emergency department is shown below.

ECG 1 

ECG is showing normal sinus rhythm at 106 beats per minute, Normal axis, PR interval of 120 msec ST segment elevation in lead V1-V5, there is also very mild ST segment elevation in lead I,avL. There is very  mild ST segment depression in lead II,III,avF so the ecg of the patient is suggestive of Acute anterolateral wall myocardial infarction.

Patient was immediately started on streptokinase thrombolytic therapy. Post thrombolysis ECG is shown below.

ECG is showing  sinus rhythm at 110 beats per minute, normal axis, PR interval of 120 msec, ST segment resolution by more than 50% in lead V1-V5 suggestive of successful thrombolysis.


So the final diagnosis is Acute anterolateral wall myocardial infarction with successful thrombolysis.

Thank you.

Inferior wall with posterior wall with right wall myocardial infarction

A 56-years old female comes with acute onset retrosternal chest pain of 6 hours duration along with palpitation, sweating, giddiness and dyspnoea. She was a known case of diabetes mellitus and hypertension since last 10 years. Her pulse at the time of admission was 68 beats per minutes, blood pressure 90/60 mmhg. ECG of patient at the time of arrival is shown below

First ECG of the patient 

 ECG is showing sinus rhythm at 70 beats per minutes, normal axis, there is ST segment elevation in lead II,III, Avf. There is marked ST segment depression in lead I, avL along with T wave inversion in lead avL Lead V1,V2,V3 is showing ST segment depression with ST segment flattening along with upright tall T wave (most prominent in lead V2), ratio of R wave / S wave in lead V2 is more than 1. So the ecg is suggestive of acute inferior wall myocardial infarction along with posterior wall myocardial infarction.

ECG with posterior lead (Posterior lead indicated by lead V4,V5,V6)

ECG is showing ST segment elevation in lead V4,V5,V6(representing posterior lead V7,V8,V9)

ECG with right sided lead (represented by lead V4,V5,V6)

ECG is showing ST segment elevation in lead V4,V5,V6

Patient was started on thrombolysis. ECG done 30 min after starting thrombolysis

 ECG is still showing ST segment elevation in lead II,III,avF along with ST segment depression in lead V2,V3

ECG done 6 hours after thrombolysis

There is significant ST segment resolution after thrombolysis ( more than 50% ST segment resolution suggestive of successful thrombolysis.

Little about ECG finding in posterior wall myocardial infarction

Posterior wall myocardial infarction (MI) occur due to occlusion of either the left circumflex or the right coronary artery. It most commonly occur with acute inferior or lateral MI; but isolated posterior wall MI can occur. 

Electrocardiographic abnormalities suggestive of acute posterior wall MI include  (in leads V1, V2, or V3): 

(1) Horizontal ST segment depression

(2) Tall, upright T wave;

 (3) Tall, wide R wave

 (4) R/S wave ratio greater than 1.0 (in lead V2 only). 

Combination of horizontal ST segment depression with an upright T wave increased the diagnostic accuracy of these two separate electrocardiographic findings. 

The additional-lead electrocardiogram using left posterior thorax leads is potentially helpful; ST segment elevation greater than 1 mm in this distribution suggests an acute posterior wall MI

Reference
Brady WJ. Acute posterior wall myocardial infarction: electrocardiographic manifestations. The American journal of emergency medicine. 1998 Jul 1;16(4):409-13.

Thank you.

PSVT

A 50 years old female came to the emergency with chief complaints of acute onset palpitation since last one hour of duration. There was no history of dyspnoea, chest pain, giddiness. Patient was a known case of diabetes mellitus since last 10 years and hypothyroidism  since last 7 years. During admission patient blood pressure was 126/70 mmhg. ECG of  the patient is shown below.

ECG during episode of tachycardia (Click  on the image to enlarge it)

ECG is showing narrow QRS complex (QRS duration in the ecg is less than 120 msec), regular tachycardia at rate around 190 beats per minutes, no visibble P wave seen anywhere, no significant ST-T wave changes are seen so the ecg is suggestive of narrow complex regular Short RP( P wave not seen, it mean P wave are most likely merged in the QRS complex, so RP interval(from the start of QRS complex to the start of P wave) is very small or < 70 msec, tachycardia. 

Differential is first most likely Atrioventricular nodal reentrant tachycardia (AVNRT), second AVRT, third atrial tachycardia.Patient was given injection adenosine, following which she achieved normal sinus rhythm. 

ECG after giving injection adenosine is shown below (Click on the image to enlarge it)

ECG is showing  normal sinus rhythm at 100 beats per minute, normal axis, PR interval 120 msec, no ST-T wave changes seen.

Patient underwent Electrophysiology study which showed dual Atrioventricular nodal physiology suggestive of AVNRT. Patient underwent successful slow pathway ablation.

Let's discuss how to approach in a patient with narrow QRS complex, regular tachycardia.

Thank you.

Acute posterior wall myocardial infarction with inferior wall myocardial infaction

A 59-years-male came with history of acute onset retrosternal chest pain of 2 hours duration. He was a chronic smoker and known case of diabetes mellitus since last 6 years and was on oral hypoglycemic agent for the same. Patient was also complaining of dyspnea, orthopnoea and paroxysmal nocturnal dyspnoea. Patient went to local hospital, ECG was done, which was suggestive of ST elevation myocardial infarction. Patient was immediately thrombolysed with tenecteplase. Patient was intubated, kept on ventilator in view of acute congestive heart failure and left ventricular dysfunction and referred to our hospital . During evaluation in emergency patient pulse was 100 beats per minute, Blood pressure 80/60 mmhg, on respiratory system examination bilateral crepitations were present.

First ECG of the patient 

ECG  of the patient is showing heart rate of 125 beats per minute, narrow QRS complex, PR interval 160 msec duration, there is ST segment elevation in lead II,III,avF. Also there is marked ST segment depression with ST segment flattening in lead V1,V2, V3. T wave in lead V1-V3 are all and upright, Tall and broad R wave in lead V1,V2, R wave in lead V1,V2 of 40 msec ( one small square), R/S ratio in lead V2 is equal to 1 (R wave height is 6 small square, and S wave depth is also 6 small square) so ecg is suggestive of posterior wall myocardial infarction.

ECG done after 5 minute

ECG is showing ST segment elevation in lead II,III, avF. There is marked ST segment depression in lead V1-V3 so the diagnosis of this patient is inferior wall myocardial infarction with posterior wall myocardial infarction.

Patient posterior lead ECG could not be done as patient was on ventilator. Patient was thrombolysed.

 

Post Thrombolysis ECG of the patient

ECG is showing normal sinus rhythm at 100 beats per min, normal axis, there is small Q wave seen in lead II,III,avF. Also mild ST segment elevation or upward convexity seen in lead II,III. There are tall T wave seen in lead V2. so ECG is suggestive of successful thrombolysis as there is ST segment resolution in the ECG.

So the final diagnosis is ST elevation posterior wall myocardial infarction with inferior wall myocardial infarction with successful thrombolysis.

Little about ECG finding in posterior wall myocardial infarction

Posterior wall myocardial infarction (MI) occur due to occlusion of either the left circumflex or the right coronary artery. It most commonly occur with acute inferior or lateral MI; but isolated posterior wall MI can occur. 

Electrocardiographic abnormalities suggestive of acute posterior wall MI include  (in leads V1, V2, or V3): 

(1) Horizontal ST segment depression

(2) Tall, upright T wave;

 (3) Tall, wide R wave

 (4) R/S wave ratio greater than 1.0 (in lead V2 only). 

Combination of horizontal ST segment depression with an upright T wave increased the diagnostic accuracy of these two separate electrocardiographic findings. 

The additional-lead electrocardiogram using left posterior thorax leads is potentially helpful; ST segment elevation greater than 1 mm in this distribution suggests an acute posterior wall MI

Reference
Brady WJ. Acute posterior wall myocardial infarction: electrocardiographic manifestations. The American journal of emergency medicine. 1998 Jul 1;16(4):409-13.

Thank you.

Presyncope in a middle age male

A 54-years male came with history of giddiness on and off along with one episode of blurring of vision since last one day. There was no history of Diabetes mellitus, hypertension or coronary artery diseases.

ECG done in the emergency department is shown below (Click on the image to enlarge it)

ECG is showing sinus bradycardia with heart rate of 50 beats per minute, PR interval was 140 msec, there was right axis deviation with complete right bundle branch block, QTc interval was 386 msec.

So from history and ecg we kept the possibility of Presyncope with Possible Sinus node dysfunction with intraventricular conduction defect. But ECG was not completely diagnostic. So holter was done.

Holter of the patient 

Holter of patient showed bradycardia with average heart rate around 50 beats per minute, there were long sinus pause maximum being of 4 sec during awake time, there was decrease heart rate variability but there was no evidence of any atrioventricular block. So in view of these holter finding patient underwent dual chamber pacemaker and later discharged in stable condition.


Thank you.

Middle age female came with palpitation, ECG showing narrow complex tachycardia

A 55 -years old female came with history  of palpitation of one hour duration. She was a known case of diabetes mellitus and hypertension since last 10 years and was on medical treatment for the same. ECG of the patient done in the emergency department is shown below.

ECG during the episode of  tachycardia

ECG is showing narrow complex regular tachycardia at rate 180 per minute, normal axis, no visible P wave seen, there were no ST-T wave changes seen. So the ecg diagnosis of the patient was kept narrow complex, regular, short RP (as P wave not visible ) tachycardia with differential diagnosis being AVNRT, AVRT, Atrial tachycardia.

Patient was given injection adenosine following which her tachycardia subsided.

ECG after giving injection adenosine

ECG is showing normal sinus rhythm at rate 114 beats per minute, normal axis, no pre-excitation visible.

Patient underwent electrophysiological study which showed dual AV nodal physiology. Patient underwent successful slow pathway ablation and was discharged in stable condition.

Lets discuss how to approach in a patient with Short RP regular, narrow complex tachycardia.

Thank you.