Seeing as to how it’s Labor Day I figured I’d go ahead and post some lazy pics, like the view from the lighthouse this morning.
How about another lazy pic? ST waves deserve a day off too. Of course if they’d just stay on their baseline they wouldn’t need a break, but that’s a story for another day.
As always, start with the rate. By the count-the-complexes-and-multiply-by-six method the rate is in the mid 80’s. The rhythm seems to be pretty clearly sinus; the lead II rhythm strip shows P waves quite clearly, and these P waves line up with smaller deflections in the other leads’ tracings.
Let’s assess the QRS’s. The QRS is a little widened, measuring somewhere between 2 and 3 little boxes wide. There’s an RSR’ of sorts as well as an extra S wave in II, which seem to indicate there is at minimum some RBBB and possibly a degree of fascicular block as well. Certainly I think we can agree that this patient has likely been hypertensive for some time. A couple people questioned delta waves. I don’t disagree that there’s an inflection point in the upstroke of the R wave in a few of the leads; that being said, putting the delta wave aside, the rest of the QRS looks narrow in most patients with WPW. That’s not to say that WPW protects a patient from developing hypertensive changes on the EKG, but most patients with an evenly wide QRS do not have WPW.
On to the ST waves. There’s no ST elevation so we don’t need to worry about calling in the cath lab team on Labor Day right? Well, not so fast. Labor Day is for LABOR, let’s see where this goes. Shall we zoom in on V2 and V3?
Clearly there’s deep depression in V2, and some present in V3 as well. We keep hitting on concordance of the depolarization and the repolarization in the setting of a widened QRS as being bad, and this EKG re-demonstrates that. Our EKG is oriented to the front of the heart, but what about the back of the heart? You can reproduce what the back of the heart is doing by turning the EKG to face a light and looking through the back of it; it’d look a lot like this:
Uh oh. Tombstones. I would argue that you have enough info right now to activate the cath lab because of Acute Posterior MI, if you want to absolutely prove it to yourself you can get a posterior EKG. I don’t have a posterior one for this patient, but it was indeed a STEMI. The clinical vignette was of this occurring in a hypertensive urgency (now emergency) setting, certainly if you weren’t leaning on the blood pressure before you need to be doing so now.
A couple comments on Posterior MI, the STD/reverse STE is commonly most prominent in V2 but remember that a lot of that is dependent upon lead placement. Posterior MI is an exception to the rule that STEMI’s have to have STE to go to the cath lab; as such this is a relatively common board question, and a clinical presentation you will see.