ECG-aVR, wellens, brugada, post MI

Question 1

Answer 1

Brugada-Type 1

Question 2

Three types of Brugada

Answer 2

Question 3

What is Wellen’s Warning?

What does it indicate?

Answer 3

Biphasic or inverted and deeply symmetrical T waves in precordial leads

Critical occlusion of LAD; impending anterior MI

Question 4

In type A Wellen’s, (biphasic T waves in precordial leads), do the T waves go up or down first?

Answer 4

up; there is initial positivity then terminal negativity

Type A happens in 25% of Wellen’s; the remainder, type B, happen in 75% and are deeply and symmetrically inverted

Type A usually precedes Type B it juts often isn’t captured on ECG

If T waes initally go DOWN then UP, think hypokalemia (the up is actually a U wave); these are called Reverse Wellen’s waves

Question 5

What does the ECG show?

Answer 5

Wellen’s Type B

Other things that can cause deeply inverted T waves in precordial leads:

Pulmonary embolism
Right bundle branch block
Right ventricular hypertrophy
Left ventricular hypertrophy
Hypertrophic cardiomyopathy
Raised intracranial pressure
Normal paediatric ECG
Persistent juvenile T wave pattern
Brugada syndrome
Hypokalaemia

Question 6

If you are worried about a posterior STEMI, what is one thing that could be done to increase your sensitivity of the ECG?

Answer 6

Posterior Leads

V7 – Left posterior axillary line, in the same horizontal plane as V6.
V8 – Tip of the left scapula, in the same horizontal plane as V6.
V9 – Left paraspinal region, in the same horizontal plane as V6.

he degree of ST elevation seen in V7-9 is typically modest – note that only 0.5 mm of ST elevation is required to make the diagnosis of posterior MI!

Question 7

What type of MI is shown?

Answer 7

inferolateral + posterior

Question 8

What is this ECG concerning for?

Answer 8

Posterior MI, see answer image for V7-V9 leads

Question 9

What is this ECG concerning for?

Answer 9

Posterior MI

The ST depression and upright T waves in V2-3 suggest posterior MI.
There are no dominant R waves in V1-2, but it is possible that this ECG was taken early in the course of the infarct, prior to pathological R-wave formation.
There are also some features suggestive of early inferior infarction, with hyperacute T waves in II, III and aVF.

Question 10

What does elevation in aVR with diffuse ST depression suggest?

Answer 10

Left main occlusion

OR

Proximal LAD occlusion

OR

severe triple vessel disease

OR

diffuse subendocardial ischemia (O2 supply/demand mismatch often after cardiac arrest resuscitation)

Question 11

Where is the occlusion?

Answer 11

LMCA

ECG shows:

Marked ST elevation in aVR >> V1
ST depression in mulitple leads (V2-6, I, II, aVL, aVF), to some extent masked by a non-specific interventricular conduction delay

Question 12

What does the ECG show?

Answer 12

LMCA occlusion

The ECG shows:

Sinus tachycardia
Widespread ST depression (V4-6, I, II, aVL)
ST elevation in aVR > V1

This patient was an elderly gentleman presenting with chest pain and cardiogenic shock (hence the tachycardia). He had a brief episode of VF whilst being transferred onto the cath lab table. Angiography revealed a LMCA occlusion

Question 13

What does the ECG show?

Answer 13

Elevation in aVR with diffuse ST depression

In this case, pt had a proximal LAD lesion (differential also included left main occlusion, triple vessel disease)

Question 14

What does this ECG show?

Answer 14

Elevation in aVR with diffuse ST depression (in this case, was a proximal LAD occlusion)

The ECG shows:

A septal STEMI, with ST elevation and Q wave formation in V1-2
ST elevation in aVR
Widespread ST depression, most prominent in leads I, II and V5-6

Question 15

What does the ECG show?

Answer 15

Elevation in aVR with diffuse ST depression (in this case, pt had severe multi-vessel disease, differential included left main and proximal LAD occlusion)

Question 16

What does the ECG show?

Answer 16

Elevation in aVR with diffuse depression

In this case, pt had a left main occlusion

Question 17

What does the ECG show? This patient had a hx of CAD, is having a massive GI bleed and has chest pain.

Answer 17

Diffuse Subendocardial Ischaemia Due To Acute Blood Loss

The ECG shows:

Sinus tachycardia + RBBB.
ST depression in a distribution typical of subendocardial ischaemia (leads V4-6, I, II), with ST elevation in aVR > 1mm.
The ST depression in V1-3 is an expected finding in RBBB, and is therefore more difficult to attribute to ischaemia.

This ECG was taken from an elderly man who presented with an acute GI bleed plus chest pain on the background of coronary artery disease. His ischaemic symptoms and ECG improved with blood transfusion. In this case the subendocardial ischaemia was likely due to cellular hypoxia (O2 supply < demand) from his acute anaemia, exacerbated by poor coronary blood flow.

Question 18

If there is ST elevation >1mm in aVR, what medical therapy should you discuss with cardiology before giving?

Answer 18

Clopidogrel

These patients are more likely than most STEMIs to need CABG/bypass. Clopidogrel treatment <7 days before CABG is associated with increased risk of bleeding (and prasugrel is associated with even more risk)

Question 19

What does the ECG show?

Answer 19

SVT with elevation in aVR and lateral lead depression

Widespread ST depression (with reciprocal STE in aVR) is a common finding in patients with supraventricular tachycardias such as AVNRT or atrial flutter. The significance of this finding in individual patients is unclear, and may be due to:

• Rate-related ischaemia (O2 demand > supply)
• Unmasking of underlying coronary artery disease (i.e. tachycardia as a “stress test”)
• A pure electrical phenomenon (e.g. the young patient with SVT who is relatively asymptomatic and has normal coronary arteries)

These findings should resolve when tachycardia resolves.

Question 20

What’s one way to help distinguish between anterior ischemia and posterior MI?

Answer 20

posterior leads