ECG of the Week - 3rd November 2014 - Interpretation

These ECG's are from a 56 yr old male who present with 2 hours of chest pain. Past history of hypertension and smoking. The ECG's were performed 15 mins apart with ongoing chest pain.
Check out the comments on our original post here.

ECG 1
On arrival to ED
Click to enlarge

Rate:

• 72 bpm

Rhythm:

• Sinus rhythm
• Single PAC (Complex #7)

Axis:

• Normal 

Intervals:

• PR - Normal (160ms)
• QRS - Normal (100ms)
• QT - 360ms

Segments:

• ST Depression leads I, V4-6

Interpretation:

• Lateral ST segment depression
• Given associated Hx of chest pain ischaemia is the main concern

ECG 2
15 mins following ECG 1
Click to enlarge

Rate:

• 72 bpm

Rhythm:

• Regular
• Sinus rhythm

Axis:

• Normal 

Intervals:

• PR - Normal (180-200ms)
• QRS - Normal (80ms)
• QT - 360ms

Segments:

• ST Depression leads I, II, aVL, V2-6
• ST Elevation lead aVR (~1mm)

Additional:

• Markedly prominent T waves leads I, V2-6

Interpretation:

• De Winter's T Wave Pattern
• Suggests acute LAD lesion requiring emergent reperfusion 
• Dynamic ECG changes compared with previous ECG

What happened ?

The ECG changes were recognised by the treating team. The patient was taken for emergency PCI which showed:

• LAD - 100% Occlusion - 2 x stents inserted
• RAC - 30% proximal stenosis

Post stent echocardiogram showed:

• Mild systolic dysfunction
• Akinesis of anterior septum and apical region
• LVEF ~40-45%

The patient was discharged after a 4 day in-patient stay.

I think there are two key learning points from this case:

1. The need for serial ECG's
2. Recognition of De Winter's T Wave Pattern

I'd encourage all our readers to check out the excellent 'De Winter's T Wave' page from the Life in the Fast Lane ECG library (link below) which has a comprehensive overview of this important ECG pattern.

References / Further Reading

Life in the Fast Lane

• De Winter's T Waves