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75 year old with chest pain: is this lateral ischemia?

Test yourself with this week’s ECG case. Then scroll down for a structured step-by-step interpretation and clinical pearl.

Clinical Scenario

A previously healthy 75 year old presents with a couple of hours of chest pressure and presyncope.

ECG

Question

The final ECG interpretation is “Sinus bradycardia. ST&T wave abnormality, consider lateral ischemia.” Do you agree?

ECG Analysis

  • Heart rate/rhythm: sinus bradycardia
  • Electrical conduction: normal intervals
  • Axis: normal
  • R-wave progression: normal
  • Tall/small voltages: normal
  • S: the lateral STD/TWI in I/aVL (which are discordant and disproportionate to the QRS) are reciprocal to inferior hyperacute T waves in III/aVF (broad based, symmetric, and large relative to QRS), with Q wave in III, and STD/TWI in V2 (reciprocal to posterior wall)

Answer

Sinus bradycardia and infero-posterior STEMI(-) Occlusion MI. Cath lab activated: RCA occlusion

Clinical Pearl

Reciprocal change may be more obvious: primary ischemic STD/TWI in aVL can point to subtle inferior STE/hyperacute T wave, and primary ischemic STD V2-4 is reciprocal to posterior occlusion MI

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