Case: 71 yo male with PMH of CAD, HTN, STEMI w/ complete occlusion of LAD 1 month prior presents with 3 weeks of bilateral lower extremity edema w/ associated dyspnea.
Initial Vital signs: BP 118/62, HR 100, RR 20, O2 sat 97%, Temp 97.2
Exam: Remarkable only for bilateral pitting edema
What is your impression of the EKG?
Let’s break it down……
1. rate ~ 99
2. Rhythm – sinus
3. Conduction intervals – wnl
4. Anything else? - YES
a. ST elevation in V1-V4
b. Q waves most noticeable in V2-V4
c. T wave inversions in precordial leads
What does this EKG finding suggest?
In this patient who just had a STEMI about 1 month ago, is this ECG more suggestive of another STEMI or something else?
Answer = Something else.
This ECG is more suggestive of Left ventricular aneurysm (LVA)
Key features of L ventricular aneurysm
1. ST elevation >2 weeks after a STEMI
2. Q waves
a. LVA in anterior wall can produce a Qr wave = deep Q followed by small R wave or a QSwave = single deep negative wave in V1-V4.
b. NOTE** - Q waves can occur within the 1st hour of a STEMI
3. T wave amplitude is small compared to QRS
a. Twave/QRS ratio <0.36 in all precordial leads think LVA
b. STEMI's more commonly have hyperacute T waves
c. Dr. Smith's blog talks about this in more detail (see link below). He found this was the best way to differentiate between LVA and STEMI
4. Lack of reciprocal ST depression
5. Lack of dynamic changes on repeat ECG
Why is this important?
Aside from the obvious STEMI vs not a STEMI conundrum, recognizing LVA is important for several different reasons. LVA increases a pt's risk of developing cardiac arrhythmias and subsequent death. It also increases the risk of developing CHF and mural thrombus.
What should be your next step in management?
Call cardiology and admit the patient. These patients will ultimately need an ECHO for official diagnosis. In discussion with cardiology consider giving patient an antiplatelet and/or anticoagulant.
Dr Smith's Blog