FL_Medic Posted April 26, 2009 Author Share Posted April 26, 2009 (edited) Ok, Fred is correct. This is an anteriolateral STEMI. The patient appears to have a normal QRS-axis probably around 60 degrees considering AVL is equiphasic, and lead 2 has the largest positive deflection. Leads 1, 2, & 3 are all positive. I am not great at reading angiography so I am going to make an educated guess. V3, V4 elevation indicates LAD occlusion while V5, & V6 indicate circumflex occlusion. This could be a proximal Left artery occlusion but judging by the degree of elevation I doubt it. Unless of coarse there is still a little bit of oxygen saturated blood passing by. Since the damage seems to be worse in the anterior leads (more ST elevation), I think it is probable that this is a proximal LAD occlusion with a large area of infarct stretching towards the lateral wall. This is hard to swallow because the angio looks more like a lateral artery similar to the circumflex. I think that if that is the circumflex it would explain anterior infarct, but the lateral infarct would be more prominent. It is possible that the LAD is feeding some of the low lateral wall causing this relatively diffuse pattern of STE. If someone out there is better at reading these, please analyze. This was caught by one of our EMS crews and the door-to-balloon time was 77min. The left is pre-cath lab, the right is post. *****Message to Moderators***** Would it be possible to get an entire thread aimed towards ECGs/Cardio?? EMS village has something similar to this and I think it would be appreciated by many on here. Considering the widespread need for more education on this topic. If you do this, please move my strip teases for me. I have a lot more to add!! *****End Message**** Edited April 26, 2009 by FL_Medic Link to comment Share on other sites More sharing options...
FL_Medic Posted April 30, 2009 Author Share Posted April 30, 2009 No one has anything to add on this? Just wanted to raise this to the top one more time before it floats into the abyss. Link to comment Share on other sites More sharing options...
p3medic Posted April 30, 2009 Share Posted April 30, 2009 No one has anything to add on this? Just wanted to raise this to the top one more time before it floats into the abyss. OK, I'll bite. It appears to be a proximal LAD lesion resulting in TIMI 0 flow resulting in no perfusion of septal branches of LAD. I see no occlusion of the circumflex. I would call this an anteroseptal infarct, but I'm no cardiologist. Nice job posting the angio w/EKG. Link to comment Share on other sites More sharing options...
fiznat Posted May 1, 2009 Share Posted May 1, 2009 (edited) Well I've only been to the cath labs and seen these images a few times, but based on what knowledge I do have about the anatomy of the coronary arteries, that looks like an occlusion of the proximal circumflex. The LAD looks entirely intact. I agree that it seems difficult to reconcile this cath with the ECG, but we should probably remember that the 12 lead ECG is not that specific of an indicator for AMI. The difference we see in lead placement could have been confounded by any number of factors ranging anywhere from differences in coronary perfusion to physical placement of the leads. Good case though! Edited May 1, 2009 by fiznat Link to comment Share on other sites More sharing options...
p3medic Posted May 1, 2009 Share Posted May 1, 2009 I believe the view on angiography isn't the same as the diagram you posted. I could also be wrong, I'm a paramedic, not a cardiologist, however I believe the posted angio is a right anterior oblique view, the vessel seen on the far left making a near vertical decent is the circumflex. Or, I could be completely turned around. Link to comment Share on other sites More sharing options...
fiznat Posted May 1, 2009 Share Posted May 1, 2009 (edited) I believe the view on angiography isn't the same as the diagram you posted. I could also be wrong, I'm a paramedic, not a cardiologist, however I believe the posted angio is a right anterior oblique view, the vessel seen on the far left making a near vertical decent is the circumflex. Or, I could be completely turned around. Wow that's interesting. I just did a google search for the right anterior oblique view and it looks just like this one. Here's an example: The caption is as follows: Fig. 1. Coronary angiogram in right anterior oblique caudal view shows a left anterior descending artery total occlusion (double arrow) and 80% eccentric lesion in the second obtuse marginal (single arrow). Here is the after: Nice catch! You must have seen this before, I would have never thought about such an odd view. ....Or maybe its common? I don't know... This certainly would better explain the injury pattern we see on the ECG. So - if I can wrap my brain around this - the view is coming from sortof over the right shoulder? That would make the circumflex (and it's posterior branches) appear on the left with the LAD on the right..... Wouldn't they have to have the patient flipped over on the table for that? Weird.... Edited May 1, 2009 by fiznat Link to comment Share on other sites More sharing options...
FL_Medic Posted May 1, 2009 Author Share Posted May 1, 2009 My original angio is from a RAO angle, I looked at it again, and it was labeled RAO, duh... Fiznat, yours is pretty cool, you can actually make out the border of the epicardium. Link to comment Share on other sites More sharing options...
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