Should the Cath Lab Be Activated?
By Ken Grauer, MD
Professor Emeritus in Family Medicine, College of Medicine, University of Florida
How should one interpret the ECG in the figure below? Unfortunately, no history is available. Should the cardiac cath lab be activated on the basis of this ECG?
The rhythm is sinus tachycardia at ~110 beats/minute. The QRS is borderline prolonged, although QRS morphology suggests a supraventricular rhythm with incomplete right bundle branch block. There is no chamber enlargement. The most remarkable finding is the presence of diffuse ST-T wave abnormalities. Significant ST depression is seen in at least seven leads (II, III, aVF, and V3-V6). There is ST elevation in lead aVR and, to a lesser extent, in leads aVL and V1.
The ECG finding of diffuse ST depression in at least six to seven leads, with significant ST elevation in lead aVR, suggests the pattern of diffuse subendocardial ischemia. Recognition of this finding should immediately suggest two categories of potential causes. First, severe coronary disease caused by left main or proximal left anterior descending artery narrowing or another form of severe two- or three-vessel coronary disease. Second, subendocardial ischemia caused by something else (e.g., sustained tachyarrhythmia, cardiac arrest, shock/profound hypotension, gastrointestinal bleeding, or anemia).
It should be apparent that information about the clinical history in this case is essential for appropriate decision-making. It turned out the patient in this case had experienced a large cerebral hemorrhage with resultant depressed mental function that was not thought to be reversible. Thus, cardiac catheterization was not performed. If, on the other hand, the history had been sudden onset of severe chest pain in an otherwise fully functional patient, then prompt cardiac catheterization to define the anatomy would have been indicated.
For more information about and further discussion on this case, please click here.
How should one interpret the ECG in the figure? Should the cardiac cath lab be activated on the basis of this ECG?
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