ACS or LBBB? ECG inside.

[fiznat]

Once again, here I am with a borderline ECG that I was hoping we could discuss.

We responded for chest pains. On arrival found an 80 y/o male in bed in no apparent distress. Nursing facility staff say that the patient is baseline demented AOx1 and does not speak often "unless something is wrong." While ambulating to breakfast, the patient apparently twice complained of chest pains and SOB.

SAMPLE stuff

The patient now will not answer questions and verbalizes no complaints. There does not appear to be any pain or respiratory distress.

Hx: HTN, High Lipids, CAD + CABG 2 years ago of 2 vessels, Angina Pectoris.

Rx: ASA, Lisinopril, Simvastatin, PRN NTG (which he did not take today), Aricept.

NKDA

Assess:

Lung sounds are clear bilateral, no JVD, no distal edema. Skin is warm/pink/dry. PEARRL. C-stroke scale is zero. Trauma assessment is negative. BGL 135

Vitals

BP: 142/70

HR: 80

RR: 21

ECG

Discuss

I see a sinus rhythm with 2-3mm ST elevations in V1 and V2, T wave inversions V4-V6. No reciprocal changes in the inferior leads. I noticed a left axis deviation and POSSIBLY some evidence of left ventricular hypertrophy.

The LVH is really the issue that I wanted to discuss with this ECG. The doc seemed sure that these ST segment changes are due directly to hypertrophy, but then again, let's count: V2 deflects larger than V1 and I add up the S wave to maybe 15mm . Adding in say another 15mm for V6 and we've got 30mm, NOT 35. I realize there is a LAD as well, which will tend to point towards hypertrophy and suggests also that there may be LVH, but this just doesn't scream out LVH to me.

In the light of this patient's history and (?) complaints of chest pains, I didn't feel confident ignoring the elevations present in the ECG. I gave 0.4mg NTG SL and 324mg ASA PO and got this ECG:

(12 lead #8 cause I had a hard time getting a clear shot but finally did)

Watcha guys think? LVH? ACS?

[ERDoc]

There are other criteria for to dx LVH (see below). I would say he meets criteria for LVH. He also looks like there is a strain pattern (look in V5 and V6). You can have isloated LAE without LVH. You would see this in conditions such as mitral regurgitation and mitral stenosis (conditions where the is significant impedance to the flow out of the atrium).

[dean83]

Also some depression in V5-6 in the second 12 lead. Need a 15 lead.

[Niftymedi911]

I would agree with the MD in this case only because of the high suspicion of stenosis or regurg simply because of his age + Hx. He has a previous event in the past which could have affected the intropric ability of the heart. The ECG readings are borderline, but if you put his hx, age, and presentation. I would be 95% sure it's just regurg because of the past event.

BTW, (I'm not putting you down in any way I'm just curious) why would you be treating the monitor and not the patient? I would definately not make him a BLS patient just because he can't talk, but his just his presentation isn't very indicative of an MI and he didn't complain of it in your presence. As you've said in description, he would verbalize chest pain or shortness of breath if it occured. Again, I'm just curious, it's kinda easy to be the monday morning quarterback.

[Inf]

inverted T in II, III, aVF :roll:

do V7, V8, V9