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ECG of the week #1: is this just vasospasm?

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

Clinical Scenario

A 45-year old presented with chest pain, with a 12-lead ECG showing STEMI. But a repeat ECG just 4 minutes later, with posterior leads at V4-6, has total resolution.

ECG

Question

Is this just coronary vasospasm?

ECG Analysis

  • Heart rate/rhythm: normal sinus
  • Electrical conduction: normal intervals
  • Axis: normal
  • R-wave progression: loss of R wave in V3
  • Tall/small voltages: normal
  • ST/T: ST elevation V2-3, and aVL with reciprocal ST depression inferiorly, all of which resolved

Answer

Transient STEMI. Angiogram showed 90% proximal LAD lesion, with peak troponin 1,000 ng/L

Clinical Pearl

Coronary vasospasm is an angiographic diagnosis of exclusion after first ruling out acute coronary occlusion with spontaneous reperfusion, which could just as quickly spontaneously reocclude

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