Answer to the Case Challenge! Where is the Culprit artery ? What is your mind just Through this ECG and Clinical Scenario?
A 50 years man who is known patient of DM and HTN with family history of CAD.
Brought to the emergency department by complaints of retrosternal chest pain since 2 hours intermittently . Troponin is not increased ! BP- 140/90, HR-112 , RR- 20 .
Answer to the Yesterday Case Challenge !
#1 -The Extent of ST-elevation is from V1 up to V6 + II, III and AVF.
Once when you want to interpret the the numbers of same territory leads such as pericordial , in fact, you are localizing the LAD. as we are seeing in this angiogram , LAD is occluded from the proximal upto Mid segment , then this should elevate the ST from V1-v4 or 5- 6. Therefore when we see as such ECG , then we should suspect either Proximal LAD occlusion or diffuse Proximal-Mid to Distal . Here we have Proximal to Mid as well as distal LAD too.
#2- There is ST elevation in II, III and AVF (inferior Leads) . So we should suspect the inferior Wall and as a general concept inferior means RCA but here our Angiogram shown LCx both large branches of Major OM(diffusely Occluded ) and OM2 occlusion . It is in-contrast to text books which Most elevation is in lead III>II and ST depression is mostly in AVL>I then , it should be RCA , here it is not , because all of patients not matching to our pocket text book , here RCA is patent with some Plaquing but the Culprit is LCx and it is also due to being large LCx branching .
#3- R-R regular , V1 grossly shown coarse “F” waves > in favor of AFL.
and Finally we have a strip from post PCI which is shown ST resolution favorably after Primary PCI.