60s man.
He was seen in the ER for chest pain that lasted for several hours. This is his first visit.
ECG recorded 5 minutes after admission.
Question: Where is the Culprit?
Can you explain ST-T changes on a 12-lead ECG?
(no hyperkalemia)
Answer
ECG of this patient 60s man.
Subsequently, we also found that he has hypertension and arteriosclerosis obliterans.
Culprit lesion was right coronary artery (RCA): seg-2.
Now, let's read the limb leads
ST elevation in inferior wall is III>aVF>II lead.
Also, ST depression is in I and aVL lead.
These strongly suggest that the culprit is RCA.
= In LCx lesions, ST depression at I, aVL is less likely to occur. =
Next, consider ST-T changes in chest leads.
The base was a three-vessel disease(TVD).
This time the culprit is the RCA.
Tall T in V1-3 was determined to be a coronary T wave in the posterior wall.
Segment 13 is chronic total obstruction.
ST depression in V5,6 was LVH and thought to be related to ischemia in the inferior wall covered by collateral blood flow.
PCI was performed on seg-2 lesion. Stent is implanted.
Blood flow to 4PD,4AV is resumed.
https://www.youtube.com/watch?v=t9g8klyCeuo
from ECG maister Dr.Riku Arai's YouTbe
When you examine a patient in shock in the ER
1) Shock and heart failure should not be overlooked in ACS!
2) The principle (ST elevation) infarct is the culprit for ACS!
3) Assume a pattern of shock/heart failure in ACS!
4) In case of RCA or LCx, consider multivessel disease!
5) Simultaneous ACS is rare! Consider the difference in timing (acute/old).
6) Estimate what kind of coronary artery lesion!
