EKGenie February 2018

Case:

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 

EKG1.jpg

+ Rate

90

+ Rhythm

Sinus, regular

+ Intervals

WNL

+ Pathology

a. ST elevation in V1-V4 b. Q waves most noticeable in V2-V4 c. T wave inversions in precordial leads

+ Diagnosis

Left ventricular aneurysm (LVA)

Key Features of LVA:

  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 QS wave = 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 data-preserve-html-node="true" 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 mangement

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.

+ Additional resources

Dr Smith's Blog: http://hqmeded-ecg.blogspot.com/2008/11/ecg-review-2_10.html

http://hqmeded-ecg.blogspot.com/2012/01/left-ventricular-aneurysm-morphology.html

LITFL: https://lifeinthefastlane.com/ecg-library/left-ventricular-aneursym/