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STEMI Without The "STE"

8/10/2015

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HPI: 57 y/o woman with remote hx of CABG/PCI presents with 2 hrs of 6-10/10 substernal chest tightness and SOB. No recent cardiac events/complaints. Initial troponin is 1.48.
Picture
EKG Interpretation: normal sinus rhythm at a rate of 71 with a normal axis. Narrow QRS complexes throughout, normal intervals. Mild ST elevation in I, aVL, and V2.  Inverted T wave in III with mild ST depression as well. No previous EKG available for comparison.

Discussion: Although this patient does not have an obvious STEMI on their EKG, there is mild elevation in I, aVL and V2 with reciprocal changes in III, a pattern similar to the South African flag.  Concern should be high for a high lateral MI which is an area of that is poorly represented by standard EKG lead placement.  In this case, the patient had an acute thrombotic occlusion of a diagonal branch of the LAD artery.
Picture
On the initial EKG, the patient has lower voltages in their limb leads as well as V3-V6.  Although they don’t have frank ST elevation ≥ 1 mm in any lead other than V2, their mild ST elevation should be concerning given the low(er) QRS voltage. Move one of the V leads higher into the left axilla (2-3 interspaces) to obtain a tracing of the high lateral wall. Make sure to discuss with Cardiology your concern for a potential STEMI despite the lack of qualifying ST elevation. 

Management:
- Obtain EKG tracing of high lateral wall
- Labs including troponins as well as CXR
- MONA, heparin
- Cardiology consult emphasizing the concern for ST changes in the setting of low QRS voltage
- Consider emergent cath for patients with persistent chest pain and persistent ST changes

By: Dr. Andrew Godfrey
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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
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      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
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    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
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      • Simulation Reading
      • Resident Wellness
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    • Individualized Interactive Instruction