![]() How about a nice universal electronic medical record (EMR) to prevent this problem? So, when a guy like this says he has no prior history and has severe chest pains with an ECG like his, the cath lab gets activated. Really, the only way to know for sure that the ST elevation on his ECG represents a left ventricular aneurysm is to have clinical history of a prior anterior MI and cardiac imaging showing the aneurysm. His symptoms were quite acute, but he knew all the key words to say. How could we have figured this out? The ECG has some good Q waves in V1-V3, which is consistent with an OLD anteroseptal MI. This guy's ECG was borderline for meeting those criteria. Second, acording to the ACC/AHA guidelines for STEMI, to diagnose an anterior ST elevation MI there must be “new ST elevation at the J point in at least two contiguous leads of ≥ 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3, and/or of ≥1 mm (0.1 mV) in other contiguous chest leads or the limb leads.” Thus, 1 mm in any two contiguous leads, EXCEPT leads V2 or V3 where the elevation must be 2 mm in men or 1.5 mm in women. Some studies show that persistent ST elevation correlates more with "dyskinetic" wall motion (myocardium moving outward instead of in during systole) and not necesarrily just with aneurysmal changes. shape of the ST elevation seen in an LV aneurysm described as "coving."įirst, there is really no clinical evidence to support this classic teaching of persistent ST elevation after MI resulting from left ventricular aneurysm.Here are some of the classic findings of left ventricular aneurysm: Wait! Then how is ST segment elevation present on his ECG? Well, that's because his LV angiogram during the cath showed that he had a left ventricular aneurysm. We found out that his initial anterior MI was 6 months ago. But he got the story wrong: He should have said chest pain for 1 to 2 days in order to truly fit his ECG pattern, not acute onset of chest pain for 20 minutes. He admitted that he knew his ECG was abnormal and mimicked an anterior STEMI and he was addicted to IV narcotics. 20 (yes, 20) in the past 6 months! Almost every hospital in the area had records of him presenting with chest pains not relieved with nitroglycerin, and then relieved with IV morphine. Actually, this was coronary angiogram No. So, why a left groin hematoma?Ī little investigating was done and we found out he DID have a prior history. I was pretty sure right femoral artery access - not left - was used. A couple of hours after the angiogram I was called to check on him due to left groin pain. He remained chest-pain-free and his cardiac enzymes remained normal throughout the hospitalization. ![]() The term "Q-wave MI" is an old term that used to refer to "transmural" infarctions resulting in Q waves in the ECG. An old anterior MI would have pathologic Q waves in the anterior precordial leads (V1-V3) and an old inferior MI in the inferior leads (II, III and aVF).įrequently we revascularize acute ST elevation MIs quite quickly and Q waves don't develop. They call this "Tombstoning" since the combination of the ST segment and the T wave look like a tombstone:Įventually the ST elevation resolves and, if the infarct completes, a "pathologic" Q wave develops like in our patient's ECG. Here is a picture of an acute anterior ST elevation MI with 5 mm of ST elevation at the J point. The second change is ST segment elevation at the J point. Here is an example of hyperacute T waves: Hyperacute T wave changes are the first ECG change during acute MI and are quite transient, so usually missed. Let's review the ECG in an acute MI briefly Here is a comparison of normal Q waves in the inferior leads compared with pathologic Q waves: ![]() ![]() They take at least a few hours, to a couple of days after an MI, to develop and can persist for a lifetime in many cases, especially if coronary revascularization is not performed quickly. These Q waves take some time to develop and would NOT be present within 20 minutes of symptom onset. What does "pathological" mean? This means a certain disease process is present, specifically myocardial infarction.
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