Massive ST Segment Elevation in Coronary Spasm
Report:
Sinus rhythm 93/min
Extensive acute anterior infarction
Comment:
The elevation settled rapidly and subsequent angiography documented normal coronary arteries. The most likely explanation is spasm, which may have caused near-drowning in the first place.
The ECG appearance, however, is that of âtombstonesâ from acute infarction. In some large anterior infarcts lead 2 shows ST elevation as well. After all, lead 2 is the sum of 1 and 3; large ST elevation in 1 will âpullâ the segment up if depression in 3 is smaller.
Spasm is of course indistinguishable from thrombotic events electrocardiographically. In Figs 51c and 51d below, the appearances are similar to those in the preceding case, but the cause was a fixed proximal LAD obstruction in a 44 year old man. All the inferior leads show more conventional reciprocal ST segment depression.
A trace 5 hours later, with the patient ventilated in ICU for cardiogenic shock persisting after angiography, is shown on the back. Troponin levels rose to over 180 µ/L. He recovered but was left with marked LV dysfunction.
51a. Resolving repolarisation changes in Casualty.
51b. Further resolution of ST segment elevation and inversion of T waves. The spasm came and went, but the damage had been done.
51c. 44 year old man, this one with fixed LAD artery obstruction.
51d. Evolving AMI, 7 hours after Fig 51c, in ICU.
52. 81 year old man with chest pain.
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