STEMI with a twist... and then a second twist!

This would make a lousy case for a EMS 12-Lead-style presentation, because it's a little to difficult to predict the outcome. And I can't really find a new EMS study, or even an old one, to present with this. If there is any lesson to learn from this case, it would have to be: patients will keep you humble.

The Patient
The history was a little iffy, as the patient was elderly and had a history of both CVAs and dementia, and was variably describing either a week of chest pain or "Nothing! I'm fine!"

EMS had called with a STEMI, though, so I met the paramedics at the ED door, and they handed me the ECG:

You know, they say "treat the patient, not the monitor," but when this shows up on the monitor, you treat that.

We grabbed another ECG after cards had been called for the cath lab activation:

By the way,  I know some sharp readers out there are already asking for right-sided leads, but V4R didn't reveal too much. But even without that, one could make a stab at guessing the infarct-related artery - it seems sort of classic. The STE in III versus aVF, the depressions in aVL and I, not to mention V2, all pointed to an RCA lesion. Intern stuff.

And then the cards fellow asks me if I've seen the patients old ECG. Oh, give me a break...

Twist #1
Now, I almost always check the old ECGs before I call cards, but in this case I was wondering how the old ECG could possibly be relevant to this clearly acute ischemia...

Ah. I see.

This ECG was recorded a number of months prior. The patient, at that time, had been brought to the hospital for another medical emergency, and was incidentally found to have an apparent STEMI. The catheterization revealed a totally occluded RCA, likely chronic.

"What a twist!"

Sooo, no cath then?

Despite the vague history the patient provided, it seemed consistent enough with AMI. There was also some concern that the collaterals that were serving her right ventricle might have acutely occluded.On top of all that, the deep drop in her blood pressure (thankfully transient) after I gave her nitroglycerin seemed to confirm the ECG. Off to the cath lab she went, leaving me feeling only somewhat less sheepish.

Twist #2
And the infarct related artery was...

"Ta-da!"

The LAD.

A "hazy appearing" lesion was visualized fairly proximally in the LAD, just before the first diagonal. Just to be sure, they used the intravascular ultrasound to confirm the freshly-ulcerated plaque, and put in a few stents. All better!

Follow-up
Well, not really. Our patient suffers from "multiple comorbidities," and did not tolerate the procedure so well. A ballon-pump was placed to support her hypotension during the procedure, and during her subsequent hospital stay any number of issues have popped up; bleeding, sepsis, renal stuff.

And her current ECG, a month later?

Huh.

Bottom line
Stay humble. I like to think that I've gotten pretty good at guessing the culprit artery in STEMI, but I was out of my depth on this one!