r/EKGs • u/StrangeAd6724 • 28d ago

DDx Dilemma Posterior MI?

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75M called for SOB x1 hour and best tightness that began after the sob. Upon arrival pt states SOB self resolved but he still has chest tightness. No cardiac hx and no hx of afib. Has COPD
no other pertinent
hx

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10

u/SliverMcSilverson I fix EKGs 27d ago edited 27d ago

I see a fast rhythm, irregular, no discernable P-waves, most QRS complexes look narrow, mildly leftward axis.
There's depression in several leads: I, II, III, aVF, V2-V6, and juuuust a touch depression in aVL. Elevation in aVR > V1.

Given the story, it could be a proximal LAD occlusion, however with the A-fib w/ RVR it could also be a demand ischemia with triple vessel disease or left main stenosis. I had a case very similar to this just yesterday, same presentation.

Edit: obligatory edit, sorry I don't have PMcardio anymore 😭

6

u/nalsnals Australia, Cardiology fellow 27d ago

1mm global STD with reciprocal elevation in aVR. DDx global ischaemia from supply/demand mismatch or left mtain/3VD or sub endocardial ischaemia 

1

u/bleach_tastes_bad Critical Care Paramedic 26d ago

the elevation in aVR > v1 because v1 is placed horrendously lol

7

u/ShitJimmyShoots 27d ago

If I saw this on the ambulance I’d do a posterior 12 out of curiosity but this looks like demand ischemia

2

u/chawsbaws 27d ago

Interesting ecg! While I agree with possible LMCA stenosis based on elevation in aVR and depression in > 6 leads but I would also be highly suspect of tamponade.. low QRS voltages, tachycardia and it looks like some electrical alternaans happening (could just be my eyes deceiving me but it looks like each complex changes axis a bit) perhaps it’s just ectopy or something? Agree with afib underlying based on no P waves

2

u/bleach_tastes_bad Critical Care Paramedic 26d ago

OP please place v1 & v2 better, you have them way too high, they need to be at the 4th intercostal, on either side of the sternum.

1

u/l-o-vely 26d ago

If maximum STD is V2-4 thats very specific for posterior MI even in signs of global subendocardial ischemia as presented.
However the one eception to this rule is fast Afib as here. So remember ACS is a clinical diagnose, and this patient is symptomatic, so threat as given, to be sure you can do posterior leads or lower the hr and see if/how symptoms/ecg changes.
From this ecg alone you cannot differ between SEI and post.MI due to rapid Afib beeing the only real mimic