- BP = 130/90 mm Hg.
- Initial hs-Troponin was normal.
- How would you interpret this ECG?
- Should you activate the cath lab?
Coronary Spasm — Teragawa article
https://pmc.ncbi.nlm.nih.gov/articles/PMC6259026/pdf/WJC-10-201.pdf
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| Figure-1: The initial ECG in today's case — obtained from a patient with new chest pain. |
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| Figure-2: XXXX |
-USE.png) |
| Figure-3: XXXX |
- ECG Blog #205 — Reviews my Systematic Approach to 12-lead ECG Interpretation.
- ECG Blog #73 — Reviews "My Take" on the ECG Diagnosis of LVH.
- ECG Blog #92 — Presents another perspective for ECG Diagnosis of LVH.
- ECG Blog #424 — Another example of when marked LVH may manifest anterior ST elevation.
- ECG Blog #461 — Another example of the differential diagnosis between LVH vs acute anterior MI vs LV aneurysm.
- ECG Blog #380 and Blog #482 — on Precordial "Swirl".
- For cases similar to today, in which LVH may mimic ischemia — Check out My Comment at the bottom of the page of the following posts in Dr. Smith's ECG Blog — the November 29, 2023 post — June 20, 2020 — March 31, 2019 — March 29, 2019 — and the December 27, 2018 post.
- ECG Blog #218 — Reviews HOW to define a T wave as being Hyperacute?
- ECG Blog #230 — Reviews HOW to compare Serial ECGs (ie, "Are you comparing Apples with Apples or Oranges?").
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- For More Material — regarding the ECG interpretation of OMIs (that do not satisfy millimeter-based STEMI criteria).
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| Figure-5: These are links found in the top menu on every page in this ECG Blog. They lead you to numerous posts with more on OMIs. |
- In "My ECG Podcasts" — Check out ECG Podcast #2 (ECG Errors that Lead to Missing Acute Coronary Occlusion). NOTE: The timed-contents of this Podcast #2 facilitate quickly finding whatever key concepts you wish to review.
- Check out near the top of the "My ECG Videos" page, those videos from my MedAll ECG Talks that review the ECG diagnosis of acute MI — and how to recognize acute OMIs when STEMI criteria are not met (reviewed in ECG Blog #406 — Blog #407 — Blog #408).
- Please NOTE — For each of the 6 MedAll videos at the top of the My ECG Videos page, IF you click on "More" in the description, you'll get a linked Contents that will allow you to jump to discussion of specific points (ie, at 5:29 in the 22-minute video for Blog #406 — you can jump to "You CAN recognize OMI without STEMI findings!" ).
- As Dr. Frick and I highlight — not only is the current "STEMI paradigm" outdated — but in cases such as the one we describe, because providers waited until STEMI criteria were finally satisfied — cardiac cath and PCI were delayed for over 1 day.
- BUT — because the cath lab was activated within 1 hour of an ECG that finally fulfilled STEMI criteria — this case will go down in study registers as, "highly successful with rapid activation of the cath lab within 1 hour of the identification of a "STEMI". This erroneous interpretation of events totally ignores the clinical reality that this patient needlessly lost significant myocardium because the initial ECG (done >24 hours earlier) was clearly diagnostic of STEMI(-)/OMI(+) that was not acted on because providers were "stuck" on the STEMI protocol.
- The unfortunate result is generation of erroneous literature "support" suggesting validity of an outdated and no longer accurate paradigm.
- KEY Clinical Reality: Many of the acute coronary occlusions that we see never develop ST elevation (or only develop ST elevation later in the course) — whereas attention to additional ECG criteria in the above references can enable us to identify acute OMI in many of these STEMI(-) cases.
Coronary Spasm — Teragawa article
https://pmc.ncbi.nlm.nih.gov/articles/PMC6259026/pdf/WJC-10-201.pdf
Tall, Pointed T Waves
Dear Dr. Grauer — I hope this message finds you well. I am writing to seek your expert opinion on a clinical case that presented some diagnostic uncertainty regarding ECG interpretation.
Case summary:
A 54-year-old male presented to our emergency department with acute chest pain and cold sweating starting at 6:00 AM. Vital signs on arrival: BP 129/92 mmHg, HR 49 bpm, RR 22/min, BT 34.2°C. Initial high-sensitivity troponin I was 0.0023 ng/mL.
The ECG was interpreted as possibly showing hyperacute T waves, prompting emergent coronary angiography for suspected STEMI. The angiographic findings revealed:
- LM: normal
- LAD: middle LAD atherosclerosis with severe coronary spasm and TIMI 0 flow, which improved after intracoronary nitroglycerin; IVUS showed mild atherosclerosis without significant stenosis (final TIMI 3 flow)
- LCX/RCA: normal or mild atherosclerosis
- SYNTAX score: 0
Final diagnosis: coronary spasm with insignificant CAD; managed medically.
Given these findings, I wonder whether the initial ECG changes should instead be interpreted as early repolarization rather than true hyperacute T waves of STEMI.
If possible, I would be most grateful for your thoughts on this ECG pattern — specifically how to distinguish hyperacute T waves from early repolarization in such cases where troponin is normal and angiography reveals no significant obstruction.
initially EKG
Thank you very much for your time and teaching. Your educational work on ECG interpretation has been invaluable to clinicians like me.
Warm regards,
Chun-Hung Chen, MD
MY REPLY:
Hi. Fascinating case. I’m attaching a 2018 article on Coronary Spasm — that I find helpful. I remember the 1980’s when Carl Pepine was studying coronary spasm at the University of Florida (which is the institution where I taught for 30 years). Coronary spasm is not that common — but is still problematic …
So your investigations PROVE this patient has coronary spasm with minimal underlying coronary disease.
I really wonder what a TRUE BASELINE ECG on this patient looks like? I see little difference between the 8:13 vs 10:37 tracings that you sent me. These ECGs are totally consistent with coronary spasm (diffuse ST elevation and very hyperacute looking T waves, but without localization and without any reciprocal ST depression!).
Can you get that ECG after IV NTG relieved symptoms ???
Can you get a true baseline ECG?
I would never call this ECG “normal”. I suspect this patient may have a “baseline” ECG that still shows ST elevation and peaked T waves — but I doubt his true “baseline” ECG will look like this.
So “early repolarization” (or a “repolarization variant” ) is a diagnosis of exclusion, after you rule out underlying disease (and rule out ongoing coronary spasm). I do not believe we yet have a “true baseline” ECG on this patient.
KEY POINTS:
— Is this patient a smoker ????? If so — absolutely EVERY cigarette must be stopped!
— I would make a copy of this patient’s ECG — and either a paper copy or scanned for his smart phone, I’d suggest that he carry this along with him so that if ever he has to go to an emergency department — he can show this ECG to medical providers.
IF you can find a true “baseline” for this patient — or if you can find his ECG after the IV NTG relieved symptoms — then I’d love to make an ECG Blog on this case.
I hope the above (and the attached article) are helpful!
BEST — :) Ken
CHEN REPLY:
Dear Dr. Grauer, Thank you very much for your detailed and insightful reply — it’s truly an honor to receive your comments.
Regarding your questions:
1. Unfortunately, there is no previous (baseline) ECG available for this patient.
2. The patient was sent directly for coronary angiography immediately after the initial ECG, so we did not obtain an ECG after IV nitroglycerin relief at that time.
3. However, we did record a third ECG after the catheterization, which is attached as the third tracing in the file.
In addition, follow-up laboratory data showed a significant rise in cardiac biomarkers:
· At 6 hours after symptom onset, hs-Troponin-I was 6.2373 ng/mL (abnormal ≥ 0.0875; reference ≤ 0.0175).
· At 12 hours, hs-Troponin-I increased to 66.1647 ng/mL (abnormal ≥ 0.0875; reference ≤ 0.0175).
Thank you again for your generous guidance and for sharing the 2018 article on coronary spasm — it was very helpful. I will continue to follow up with this patient and will send you any further ECGs if available.
Warm regards — Chun-Hung Chen, MD
MY REPLY:
Thanks for the followup. I think i will write this case up! As usual - I will acknowledge you, and let you know when i publish it! Thank you! — : ) Ken
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Me to write Chun back — there IS a difference between ECG-1 and -2 !!!! ECG-2 looks more benign, less symmetric — so more like early repol! Wish we had an ECG right after IV NTG and wish we had a baseline ECG !!!!
SSmith — Hyperacute T waves are more symmetric. The T waves of early repol have a slower upstroke than downstroke, and thus more cocavity!
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