Tuesday, October 9, 2012

Transient Inferior OMI, with RV OMI, missed. It became obvious on a near fatal stress test.

A middle-aged woman with a history of hypertension presented with typical chest pain.  Her BP was 160/80.  Here was her presenting ECG, with chest pain:

Inferior leads show hyperacute T-waves and reciprocal STD in aVL, with a reciprocally hyperacute T-wave in aVL.  This is all but diagnostic of inferior OMI. 
 
There is also subtle STE in V1-V3.  In the context of the inferior OMI, this is diagnostic of right ventricular OMI (RVMI).


The pain improved with Nitroglycerine.  Creatinine was 4.3.  She underwent another ECG at 6 hours (when she was pain free):
The T-waves in leads II, III, and aVF are now significantly smaller, and there is terminal T-wave inversion in III, with reciprocal down-up T-wave in aVL.  These are signs of reperfusion.   The T-wave in I has also changed.
Now these reperfusion findings make the first ECG absolutely diagnostic of OMI

The troponin peaked at 16 ng/mL (also retrospectively diagnostic of OMI) and there was a "probable" inferior wall motion abnormality.

Because the patient had advanced renal insufficiency and because there was "no evidence for a current of injury on her presenting EKG's", a non-invasive approach was undertaken.  While undergoing a stress test as a part of the non-invasive approach, she developed chest pain and hypotension and had this ECG:

There is sinus bradycardia with massive inferior ST elevation, as well as ST elevation in V1-V3, diagnostic of inferior and right ventricular (RV) STEMI.  When there is ST elevation due to RVMI in V1-V3 in a left sided ECG, it is also called a "Pseudoanteroseptal MI".
She went immediately to angiogram and had occlusion of the RCA at the ostium.

Looking back, one can see ST elevation in V1-V3 on the initial ECG that is nonspecific, but, in retrospect, is probably due to RV Injury.





1 comment:

  1. Dr. Smith, in the first ECG T wave can be seen high in relation to qrs greater in DIII, in addition to depression st in DI. It would have been useful to record leads V3R, V4R on the basis of st segment elevation in V1.
    Clinical case very instructive.
    Thank you Dr. Smith
    Vittorio Masciulli

    ReplyDelete

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