ECG Video Blog #406 — To Do Additional Leads?

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 CLICK HERE — for a Video presentation of this case! (19:40 min.)

• Below are slides used in my video presentation.
• For full discussion of this case — See ECG Blog #351 —

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The ECG in Figure-1 — was obtained from a previously healthy older man who contacted EMS (Emergency Medical Services) because of "chest tightness" that began ~1 hour earlier. Given this history:

QUESTIONS: 

• How would YOU interpret the ECG in Figure-1?
• Should you activate the cath lab ?

Figure-1: The initial ECG in today's case — obtained by EMS at the scene, from an older man with ~1-hour of chest "tightness". (To improve visualization — I've digitized the original ECG using PMcardio).

Figure-4: ECG findings to look for when your patient with new-onset cardiac symptoms does not manifest STEMI-criteria ST elevation on ECG. For more on this subject — SEE the September 3, 2020 post in Dr. Smith’s ECG Blog with 20-minute video talk by Dr. Meyers on The OMI Manifesto. For my clarifying Figure illustrating T-QRS-D (2nd bullet) — See My Comment at the bottom of the page in Dr. Smith’s November 14, 2019 post.

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ECG Blog #205 = The Systematic Approach I favor ...

• The "formula" = https://tinyurl.com/KG-Blog-2XX
• LINK for Blog #205 = https://tinyurl.com/KG-Blog-205 -

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Figure: The Systematic Approach that I favor. Review of the first 4 parameters in Descriptive Analysis (Rate; Rhythm; Intervals; Axis). NOTE: IF the QRS complex is wide — then STOP and find out WHY the QRS is wide before proceding to assessment of Axis, Chamber Enlargement and QRST Changes. This is because IF the QRS is wide because of BBB (Bundle Branch Block) — criteria for axis, hypertrophy, and ST-T wave changes will be different when there is BBB or IVCD! To emphasize, IF the QRS is wide — this is the ONE time that I depart from the sequence in Figures-2 and -3 (P.S. IF the QRS is wide — Make sure that the rhythm is not VT. If the rhythm is sinus — ECG Blog #204 reviews how to determine if RBBB, LBBB or IVCD is present).

 

Figure: The Systematic Approach that I favor (Continued). Review of the last 2 parameters in Descriptive Analysis (Chamber Enlargement; Looking for Q-R-S-T Changes) — and then formulating your Clinical Impression.

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Figure: I've added the mirror-image of leads V3 and V4 to today's tracing — to illustrate how the initial ECG shows a positive "Mirror" Test suggestive of acute posterior OMI.

Figure: The repeat ECG.

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Related ECG Blog Posts to Today’s Case:

• ECG Blog #205 — Reviews my Systematic Approach to 12-lead ECG Interpretation.
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• ECG Blog #193 — illustrates use of the Mirror Test to facilitate recognition of acute Posterior MI. This blog post reviews the basics for predicting the "Culprit" Artery (as well as reviewing why the term "STEMI" — should replaced by "OMI" = Occlusion-based MI).
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• ECG Blog #285 — for another example of acute Posterior MI (with positive Mirror Test).
• ECG Blog #246 — for another example of acute Posterior MI (with positive Mirror Test).
• ECG Blog #80 — reviews prediction of the "culprit" artery (and provides another case illustrating the Mirror Test for diagnosis of acute Posterior MI).
• ECG Blog #317 — reviews another case regarding use (or not) of Posterior Leads.
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• ECG Blog #184 — illustrates the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL (featured in Audio Pearl #2 in this blog post). 
• ECG Blog #167 — another case of the "magical" mirror-image opposite relationship between lead III and lead aVL that confirmed acute OMI.
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• The February 16, 2019 post in Dr. Smith's ECG Blog — My Comment (at the bottom of the page) emphasizes utility of the Mirror Test for diagnosis of acute Posterior MI. 
• Diagnosis of an OMI from the initial ECG — Serial tracings with spontaneous reperfusion — then reocclusion! — See My Comment at the bottom of the page in the October 14, 2020 post on Dr. Smith's ECG Blog.
• Acute OMI that wasn’t accepted by the Attending — See My Comment at the bottom of the page in the November 21, 2020 post on Dr. Smith’s ECG Blog.
• Another overlooked OMI (Cardiologist limited by STEMI Definition — OMI evident by Mirror Test) — See My Comment at the bottom of the page in the September 21, 2020 post on Dr. Smith’s ECG Blog.
• Recognizing hyperacute T waves — patterns of leads — an OMI (though not a STEMI) — See My Comment at the bottom of the page in the November 8, 2020 post on Dr. Smith's ECG Blog.
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• ECG Blog #271 — Reviews determination of the ST segment baseline (with discussion of the entity of the entity of diffuse Subendocardial Ischemia).
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• ECG Blog #266 — Reviews distinction between Posterior MI vs deWinter T waves (with anterior terminal T wave positivity reflecting "Reperfusion" T-waves).
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• ECG Blog #258 — How to "Date" an Infarction based on the initial ECG.
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• ECG Blog #294 — Reviews how to tell IF the "culprit" artery has reperfused.
• ECG Blog #230 — Reviews how to compare Serial ECGs.
• ECG Blog #115 — Shows how dramatic ST-T changes can occur in as short as an 8-minute period.
• ECG Blog #268 — Shows an example of reperfusion T waves.
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• ECG Blog #190 — How to diagnose acute RV MI (and use of right-sided leads).