Indigestion — ECG cases

The case

66-year-old man. Indigestion

HTN, T2DM (metformin, ramipril). Smoker, 15/day. No known heart disease.

On arrival

SpO2: 96% on air
Heart rate: 78
Temperature: 36.8 °C
Blood pressure: 146/90
Respiratory rate: 20

Stage 1 of 3

Heavy retrosternal pressure from 03:00, thought indigestion. Presented 9 h after onset when found grey and sweating. Pain ongoing, 6/10.

Chest clear, no murmurs. On-site PCI.

Tracing 1 of 2 for the quiz “Indigestion”. — 12-lead, 25 mm/s, 10 mm/mV Open this tracing in the studio

Most likely diagnosis?

AAcute anterior STEMI Correct answer Your answer
BOld anterior MI with persistent STE Your answer
CAcute pericarditis Your answer
DBenign early repolarisation Your answer

Convex STE in contiguous anterior leads + ongoing pain = anterior STEMI until proven otherwise.

Onset 9 h ago, pain ongoing. Next step?

AActivate cath lab for primary PCI Correct answer Your answer
BAwait troponin before angiography Your answer
CThrombolyse in ED, then refer Your answer
DMedical therapy; reperfusion window passed Your answer

Late presentation reduces, but does not remove, reperfusion benefit, especially in the presence of ongoing chest pain, recurrent/refractory electrical instability, and/or cardiogenic shock

Stage 2 of 3

Proximal LAD occlusion which was stented.

Six months later: 2 weeks breathless on stairs; brief palpitations yesterday. No chest pain today. Aspirin, ticagrelor, atorvastatin, bisoprolol, ramipril. ED registrar sees STE V2–V3, about to call the cath lab. Six-week clinic ECG in the notes.

Tracing 2 of 2 for the quiz “Indigestion”. — 12-lead, 25 mm/s, 10 mm/mV Open this tracing in the studio

Observations

SpO2: 95% on air
Heart rate: 78
Blood pressure: 118/74
Respiratory rate: 18

Bloods

Potassium (mmol/L): 4.4
hs-Troponin T at 0 h (ng/L): 17
hs-Troponin T at 1 h (ng/L): 18

Most likely cause of STE V2–V3 today?

ALV aneurysm after anterior MI Correct answer Your answer
BAcute LAD stent thrombosis Your answer
CPost-infarction pericarditis Your answer
DWellens syndrome Your answer

What discriminates best between acute ischemic ST elevation and a post MI aneurysm ECG?

AQS and STE in a pain free patient Correct answer Your answer
BSTE <5 mm in every lead Your answer
CQTc < 500 Your answer
DPatient is in sinus rhythm Your answer

T/QRS ratio is helpful in discriminating LV aneurysm and ongoing STEMI. A ratio of > 0.22 of the summed T amplitudes in V1-V4 and the summed QRS amplitudes in V1-V4 might predict ongoing ischemia. (Smith 2005; Klein 2015)

Stage 3 of 3

Cath lab not activated. Echo: thin, dyskinetic anterior wall and apex, bulging in systole; EF ~35%; 1.6 cm rounded apical echodensity moving independently of the wall. Two runs of NSVT overnight.

Diagnosis

LV aneurysm with apical thrombus after late-reperfused anterior STEMI

Late-reperfused anterior STEMI → LV aneurysm with apical thrombus at six months.

ST-elevations in V2-V3 with QS complexes in a pain free patient post MI is a classic ECG sign of LV aneurysm. When in doubt or if the patient has ischemic symtoms, it is best to discuss with the PCI lab regarding the decision to do a new angiogram.

References

Smith SW. T/QRS ratio best distinguishes ventricular aneurysm from anterior myocardial infarction. Am J Emerg Med. 2005;23(3):279-287.
Klein LR, Shroff GR, Beeman W, Smith SW. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med. 2015;33(6):786-790.
Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-3826.

This tracing was generated, not recorded. It opens in the studio with every dial live.

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Discussion

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