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July 2006 EKG case Answers You are called to see a 29 year old male in the emergency department who has dull substernal chest pain intermittently for 2 days. There is no relevant past medical history. What does the EKG show and what is your diagnosis? Rate: 55 Rhythm: sinus Axis: normal PR: normal QRS: normal T: biphasic T waves V1-V3, II, III, AVF, AVR, AVL, V6 Deep symmetrical T wave inversion V4-V5 EKG diagnosis: anterior subendocardial (non Q wave) MI or ischemia Clinical diagnosis: unstable angina Practice Points: -the EKG shows obvious T wave inversion in V2-V6. This is compatible with ischemia or subendocardial infarction if associated with an enzyme rise. -Subendocardial infarcts do not involve the full thickness of the myocardium and are less common than transmural infarcts. They are often called non Q wave infarcts. -The diagnosis of subendocardial infarction is based on a typical history of chest pain, EKG changes (ST segment depression, ST segment elevation, and T wave inversion) and cardiac enzyme elevation; the latter is often less marked than in transmural infarction. -It is important to follow up patients with a subendocardial infarction as they have lower in hospital mortality but higher reinfarction rates. -Subendocardial infarcts account for approximately 20% of all infarcts and will often progress to a Q- wave infarct within a year. -Patients with a subarachnoid hemorrhage may have very similar EKG changes, which are thought to be related to the release of noradrenaline. |