Third time’s the charm

We’ve been experimenting a little with hitting and then re-hitting on some themes of late.  Sgarbossa criteria came up relatively recently and then again on the recent sim lab test, and it’s important again for this EKG.

~85 y.o. woman with shortness of breath

As always, have a system.  The heart rate is a little under 80, the lead II rhythm strip shows pretty obvious P’s before every QRS and a QRS after every P so it’s a sinus rhythm.  We probably don’t talk enough about axis here, but it’s up in I but down in aVF meaning left axis.  Going along with the left axis we see a QRS that’s about 3 little boxes wide with a discordant repolarization (the ST waves are opposite the QRS), so there’s a LBBB present as well.

Let’s take a closer look at the anterior chest leads.


Fairly clearly there’s elevation, about 2 mm in V1, about 3mm in V2, and a little over 3mm in V3.  One of the classic Sgarbossa teachings state 5mm of STE in the chest leads is likely indicative of STEMI (which is true).  Modified Sgarbossa criteria add that STE that’s over 25% of the S wave also likely indicates MI.  That’s certainly true for V3.  Leaving Sgarbossa aside for a moment, the morphology of the ST wave in V3 does not cove up the way V1 and V2 do, adding to the ominousness of V3.

Let’s look at V4.


This is a feature we’ve hit on several times now.  Concordant STE in the setting of LBBB is an acute MI.

The troponin of this ~85 y.o. woman having an Acute Anterior MI was approximately 5.  Unfortunately for the follow-up on this case she/family did not consent to heart catheterization, but I think we can make a pretty good guess at what her anatomy would have revealed.

Almost all of you got this one right; we’ll have to re-visit it again in the future to make sure it stays fresh…

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