ECG of the week 110


ECG Case : Wellens syndrome, deep anterolateral T-wave inversion, critical LAD stenosis 

These ECGs were taken from a 40 yr old male who presented with a 60 minute history of central chest pain. 

On arrival to the Emergency Department he was pain free (ECG 1). Four minutes later he developed further intense chest pain and a repeat ECG was performed (ECG 2).

Describe and interpret ECG 1

ECG 1

Description and interpretation of ECG 1

-Rate:

  • 72 bpm

-Rhythm:

  • Regular
  • Sinus rhythm

-Axis:

  • Normal

-Intervals:

  • PR – Normal (160ms)
  • QRS – Normal (100ms)
  • QT – 400ms (QTc Bazett 440 ms)

-Segments:

  • ST elevation lead V1 (<1mm)

-Additional:

  • Biphasic T wave lead V2
  • T wave inversion leads I, aVL, aVR, V1, V3-6
    • Deep inversion leads V3-5 
  • Voltage criteria for LVH

-Interpretation:

The differentials of deep T wave inversion are relatively broad but in a patient with a history of chest pain, a pain free ECG and these ECG features the major concern is Wellens syndrome – signifying a critical LAD lesion.

The subsequent ECG, taken whilst having chest pain, highlights the need to recognize the Wellens pattern.

 

Describe and interpret ECG 2

ECG 2

-Rate:

  • 84 bpm

-Rhythm:

  • Regular
  • Sinus rhythm

-Axis:

  • Normal

-Intervals:

  • PR – Normal (160ms)
  • QRS – Normal (100ms)
  • QT – 360ms (QTc Bazett 430 ms)

-Segments:

  • ST Elevation leads I (<1mm); aVL (1 mm); V1 (1mm); V2 (6mm); V3 (7mm); V4 (7mm); V5 (4mm); V6 (1-2mm)
  • ST Depression leads III, aVF

-Additional:

  • Note resolution of deep T wave inversion with hyperacute T waves on ST segments in leads V2-3
  • Voltage changes as above

-Interpretation:

  • Antero-lateral STEMI
    • Occlusion of critical lesion suspected from first ECG

 

by Dr John Larkin, last update June 15, 2019- www.litfl.com