Syncope, Chest Pain, and LAD Occlusion – Part 2

This is the conclusion to Syncope, Chest Pain, and LAD Occlusion – Part 1.

Let’s take another look at the 12-lead ECG.


There is a regular rhythm at a rate of 60 (using the large block method there are 5 blocks between R-waves). The QRS complex is narrow at 86 ms. There are P-waves in a 1:1 relationship with the QRS complex. The PR interval is 142 ms. This is normal sinus rhythm.

This 12-lead ECG is an excellent example of why single lead monitoring is not enough.

Lead II looks perfectly normal!

The frontal plane axis is normal at 55 degrees. There is market ST-segment elevation in leads V2-V5. There is also ST-segment elevation in leads I and aVL. When LAD occlusion “crosses over” from the precordial leads to the high lateral leads we should look for reciprocal ST-segment depression in the inferior leads, and here we see downsloping ST-segments in lead III and aVF.

There is little doubt the patient is suffering acute STEMI.

On arrival at the hospital the cath team was waiting in the Emergency Department. He was taken to the cath lab where angiography revealed a proximal occlusion of the left anterior descending (LAD) artery. A stent was placed. The patient made a full recovery.

Let’s take a look at the angiograms.


Normal RCA


Proximal occlusion of the LAD


After lesion was crossed with a wire.

Updated 01/10/2015

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