ST Depression Myocardial Infarction

Report:

Sinus rhythm 97/min

Possible LVH

ST segment depression consistent with infarction/ischaemia

Comment:

This is the worst ECG presentation for acute infarction – worse than T wave inversion or ST segment elevation77. The pattern is, in fact, that of main left coronary artery stenosis – diffuse depression with ST elevation in aVR > V1, as seen here. Infarction cannot be, of course, diagnosed on repolarisation changes alone – not without supporting laboratory and clinical data.

I arranged for this patient to return home to die, but it was not to be (Fig 106a, from my old ECG Library).

In Figs 106b and 106c , the extent of ST depression is more limited, but remained fixed over 72 hours, when the patient was sent to Sydney for possible surgery. The enzymes confirmed infarction, as in the case above. At angiography there were 90% stenoses in LAD, right and left circumflex arteries – more than the “main left” equivalent!

106a. Back page from my old Library.

The ECG evolved day later to low-voltage LBBB seen here; it persisted until the patient’s death.

The reason I am no longer sure I was right in sending this patient home is that palliative care was not developed in those days and that, perhaps, the family prefers to see “everything done” before the final parting. Only if a clear-minded patient asked me himself not to admit him would I now send him back home.

Even counterpulsation would not be excluded now, when acute intervention is possible.

106b. Less global ST segment depression. It could “pass” for acute posterior MI except that the same pattern persisted over three days, unchanged.

106c. Admission ECG, basically the same as in Fig 406b.

107. 45 year old man with severe angina pectoris.