55 year old male CC: Chest pain? – Conclusion

Here’s the conclusion to 55 year old male CC: Chest pain?

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

This is a real challenge because it meets the voltage criteria for left ventricular hypertrophy in the limb leads and the lateral leads have the general appearance of “strain pattern” (or secondary depolarization abnormality).

However, leads V2-V4 just don’t look right. Unlike the limb leads, the precordial leads do not meet the voltage criteria for left ventricular hypertrophy (we would expect deeper S-waves in leads V2 and V3).

In fact, these are not S-waves at all, but rather Q-waves (absent R-wave progression). In addition, the amplitude of the T-wave in lead V4 does not seem proportional to the size of the QRS complex.

This is a very suspicious ECG, in spite of the fact that the patient was apparently asymptomatic at the time of EMS evaluation.

The 12-lead ECG was transmitted to the emergency department.

The ED physician was able to determine that the patient had received a negative stress test several years prior after a routine exam showed an abnormal ECG.

Here is the old ECG (please forgive the quality as it was faxed and then scanned).

Here was the patient’s ECG on admission to the emergency department.

Based on the patient’s hypertension and ST-elevation in leads V1-V3, the ED physician consulted cardiology.

The patient was prescribed Lopressor 5 mg IV (a total of 3 doses) and Norvasc 5 mg po which was effective in lowering the patient’s blood pressure.

Chest x-ray was negative for acute cardiopulmonary disease.

Cardiac biomarkers came back positive.

  • CPK: 256 (24-195)
  • CKMB: 8.45 (< 6.73)
  • TROP T: 0.020 (< 0.010)

Bedside 2D echocardiogram showed left anterior and apical akinesis with an EF < 35%.

Based on these findings the patient was sent emergently to the cardiac cath lab.

The LAD was totally occluded just after the first septal perforator before the first significant diagonal branch. Left-to-left and right-to-left collaterals fill the mid and distal vessel.

Attempts at crossing the area of occlusion in the proximal LAD were unsuccessful and balloon dilatation was not performed.

Conclusions:

1. Two-vessel coronary artery disease with 100% chronic occlusion of the proximal left anterior descending with 50% narrowing in the ramus intermedius branch and 50% proximal left circumflex narrowing in a right dominant system.

2. Severely reduced left ventricular systolic function, left ventricular ejection fraction of 35% with a large area of anterolateral and apical wall motion abnormality.

3. Mildly elevated left ventricular filling pressures.

4. Unsuccessful attempt at crossing the chronically occluded proximal left anterior descending, despite attempts with 3 different guidewires.

Patient will be treated medically. He will have an evaluation for viability of the anterior wall and apex. If this is scar he will be treated medically. If there is a large area of viable muscle consideration will be given for CABG surgery.

Discharge diagnosis: Coronary atherosclerosis, Hypertension, Hyperlipidemia

2 Comments

  • Troy says:

    Poor guy. EF<35%, Unsuccessful cath, chronic occlusion…..no bueno. Did they not want to try some tPA? My guess is you'll see this guy again, when he has a ventricular rupture

  • VinceD says:

    I know the date is blacked out, but is there any way of knowing how old that prior ECG was? It looks like a pretty nice Wellen’s sign on there, maybe a hint of the impending LAD badness…

    I think the comparison with the in-hospital ECG is a nice example of why precordial lead placement is so important: Either the ambulance was slightly off, leading to R-wave progression much poorer than normal, or the hospital was off, masking the poor R-wave progression a bit. When we’re going to be doing close-reading of these ECG’s, it’s important that we set ourselves up for success by taking the time to run the test in a way that will give us the most useful results. As always, a great case and discussion Tom.

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