ECG Blog #171 (Culprit Artery - Repolarization Variant vs OMI - Mirror-Image)

The only information provided on the patient whose ECG is shown in Figure-1 — was that the patient was a 54-year old man. NO history was available.

• IF this tracing was in your “pile-of-ECGs-to-be-read” — What would you do?

Figure-1: 12-lead ECG obtained on a 54-year old man. NO history available. What are your thoughts? (See text). NOTE — Enlarge by clicking on the Figure.

Descriptive Analysis:

• Rate & Rhythm — The rhythm is sinus bradycardia at a rate between 55-60/minute.
• Intervals — The PR, QRS and QTc intervals are all normal. If anything, the QTc is relatively short (I measure ~380 msec).
• Axis — The mean QRS axis is normal (about +75 degrees).
• Chamber Enlargement — None.

Looking next at Q-R-S-T Changes:

• Q Waves — Small and narrow q waves are seen in the infero-lateral leads (ie, in leads II,III,aVF; and V4-thru-V6).
• R Wave Progression — Transition occurs normally (here, between leads V2-to-V3) — albeit the R wave in lead V2 has already become relatively tall (~7 mm).

Regarding ST-T Wave Changes:

• There is 1-1.5 mm of concave-up ST elevation in each of the inferior leads (ie, in leads II,III,aVF). The mirror-image opposite ST-T wave picture of what we see in lead III appears in lead aVL. In addition — there appears to be 1 mm of flat ST segment depression in lead I.
• In the chest leads — there is ~1.5 mm of J-point ST depression in lead V2. As has been previously mentioned — this occurs in association with an R wave in lead V2 that is already surprisingly tall (~7 mm).

Figure-2: Schematic representation of mirror-image relationships from Figure-1 (See text).

Putting It All Together: The KEYS to interpreting this tracing lie with appreciating several mirror-image relationships (Figure-2):

• When ST segment elevation in the inferior leads is acute — there is an almost “magic” mirror-image relationship between the way the ST-T wave looks in lead III, compared to lead aVL. These 2 leads are nearly 180 degrees opposed to one another — therefore they show reciprocal changes.
• Note in Figure-2 — how the mirror-image of the ST-T wave in lead aVL (within the light BLUE insert) — looks identical to the shape of the elevated ST-T wave in lead III (within the WHITE rectangle).
• Similarly, the mirror-image of the elevated ST-T wave in lead III (within the light BLUE insert) — looks identical to the shape of the inverted ST-T wave in lead aVL (within the WHITE rectangle).
• Confirmation that the above mirror-image relationships are real and represent an acute change consistent with acute inferior MI — is forthcoming from the clearly abnormal shelf-like ST depression we see in lead I.
• Further support of recent (if not ongoing acute) occlusion of the RCA (Right Coronary Artery) — is suggested by the positive Mirror Test we see for the QRST complex in lead V2 (For more on the Mirror Test — See ECG Blog #80). Anterior leads (ie, leads V1, V2 and/or V3) often manifest the mirror-image opposite picture of ongoing events in the left ventricular posterior wall — and the mirror-image of the QRST complex in lead V2 (within the light BLUE insert) shows a large Q wave + downward coved ST elevation, that leads to beginning T wave inversion.

BOTTOM Line: One has to interpret the ECG in Figure-1 as consistent with recent (if not ongoing acute) RCA occlusion until proven otherwise. Since this tracing was in your “pile-of-ECGs-to-be-read” — the responsibility falls on YOU to immediately look up the patient to find out WHAT is going on?

• In addition to acute infero-postero MI — there may also be acute RV involvement in Figure-1 — since rather than ST depression, the ST segment in lead V1 is not at all depressed as would be expected with acute posterior MI. That said — right-sided chest leads would be needed to know for certain if there is or is not associated acute RV involvement.

P.S. — Unfortunately — follow-up in this case is lacking. The patient was seen years ago — and I have no further information on the case. Nevertheless, I thought it worthwhile to discuss how even when no clinical information is available — how the mirror-image opposite relationships we see in this tracing tell us we have to assume these ECG changes are acute until we prove otherwise.

ECG Blog #170 (Atypical Chest Pain - Mirror Image - Troponin - Lcx - Lad)

The ECG in Figure-1 was obtained from a 30-year old man with an unusual story. He was admitted to the hospital to “Rule Out MI” — with what was described as “atypical” chest pain, that was not thought to be cardiac in etiology. Serial troponins were negative. His initial ECG (not shown) was interpreted by a capable emergency physician as “normal”. The patient had a normal Stress Echo, in which he attained his target heart rate and showed no wall motion abnormality. He was about to be discharged from the hospital with a diagnosis of atypical non-cardiac chest pain. His pre-discharge ECG ( = ECG #2) is shown in Figure-1. There were no new symptoms at the time ECG #2 was done. How would you interpret this pre-discharge ECG ( = ECG #2)?

• What would you do, given that all testing to this point had been normal?

Figure-1: This is the follow-up ECG, obtained on this 30-year old man who was about to be discharged from the hospital. His initial ECG (not shown) was interpreted as “normal”. Serial troponins, and Stress Echo were completely normal (See text).

COMMENT: We can’t comment on the initial ECG — since it is not shown. What we can say — is that ECG #2 is not a normal tracing! Presumably, had the initial ECG been as abnormal as this 2nd ECG — the capable clinician who interpreted that initial tracing would presumably have at least seen some of the abnormalities — BUT — We can’t comment on what we are not shown ...

Descriptive Analysis of ECG #2:

• Rate & Rhythm — It’s hard to be certain what the cardiac rhythm is! This is clearly a supraventricular rhythm — because the QRS complex is decidedly narrow. But there is no long lead rhythm strip. The R-R interval is not completely regular. It looks like there is atrial activity in front of some QRS complexes — but a clearly upright P wave is lacking in lead II. I’d guess this is an ectopic atrial rhythm, perhaps with some junctional escape beats — but I can’t rule out the possibility of a nearly regular AFib. A longer period of monitoring is clearly needed to determine for certain ... Bottom Line: The above said — Since the rhythm is supraventricular, we can assess ST-T waves in ECG #2 for potential ischemic changes!
• Intervals — The PR interval is irrelevant in this tracing — since we don’t see consistent atrial activity. As noted — the QRS complex is narrow. The QTc interval appears to be normal.
• Axis — The mean QRS axis is normal (about +25 degrees).
• Chamber Enlargement — None.

Looking next at Q-R-S-T Changes:

• Q Waves — Small and narrow q waves are seen in high lateral leads I and aVL.
• R Wave Progression — Transition occurs normally (here, between leads V2-to-V3) — albeit abruptly (ie, the QRS was almost all negative in lead V2 — and abruptly becomes almost all positive by lead V3).
• Regarding ST-T Wave Changes:
• There is 1-2mm of concave-up ST elevation in leads I and aVL. The mirror-image opposite ST-T wave picture of what we see in lead aVL appears in lead III. Of note — there is ~2mm of J-point ST depression in lead III — and 1-1.5mm of J-point ST depression in leads II and aVF.
• The ST-T wave in lead V2 is somewhat distorted by artifact (ie, the contour of the ST segment in V2 is not at all smooth). That said — the T wave looks disproportionately peaked in V2, with a disproportionately wide base — however, other than nonspecific ST-T wave flattening in leads V4-thru-V6, there do not appear to be acute changes in the remaining chest leads.

Putting It All Together: The limb leads in ECG #2 are clearly abnormal. ST elevation in high-lateral leads — with a mirror-image opposite appearance of the ST-T in lead aVL compared to lead III should suggest an acute cardiac event until you prove otherwise (For more on this point — Please see My Comment at the bottom of the page in the 10/6/2018 SSmith ECG Blog post).

Follow-Up on This Case: Based on the abnormal pre-discharge ECG in Figure-1 — the cardiologist took this patient to the cath lab. He was found to have a very tight stenosis of a dominant LCx (Left Circumflex) coronary artery — which was successfully stented.

• It is fortunate that this pre-discharge ECG was obtained and interpreted before sending this patient home.
• Learning Point: The initial ECG in a patient with significant coronary disease may not always be abnormal. Serial troponins and stress testing may also be normal. None of this rules out the possibility of severe underlying coronary disease.