Emergency Department ECG
LM– no angiographic stenosis noted
LAD– Proximal LAD has luminal irregularities, the mid LAD has a patent stent, the distal LAD has luminal irregularities. D1 is a small vessel, D2 is a larger vessel, no angiographic stenosis seen in both vessels
LCx– normal caliber vessel giving rise to a large OM1 branch, no angiographic stenosis seen
RCA– Dorminant vessel, proximal to Mid RCA has a hazy 90% stenosis in the stent body, just distal to the stent there is are 2 sequential stenosis, up to 60%, distal RCA has no angiographic stenosis. The ostium of the PDA has 40% stenosis. The PLV has luminal irregularities, the distal PLV has TIMI 1 flow
Intervention: Stents placed to proximal and mid RCA
- Right side MI
- Complicates 40% of inferior MIs
- Right ventricle is preload dependent which may lead to hypotension if Nitroglycerin is administered. Treat with IV fluids and rapid transport.
- Right side ECG
- A complete set of right-sided leads is obtained by placing leads V1-6 in a mirror-image position on the right side of the chest (see diagram, below).
- It may be simpler to leave V1 and V2 in their usual positions and just transfer leads V3-6 to the right side of the chest (i.e. V3R to V6R).
- The most useful lead is V4R, which is obtained by placing the V4 electrode in the 5th right intercostal space in the midclavicular line. ST elevation in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI.
- Inferior MI
- 40-50% of all myocardial infarctions.
- more favorable prognosis than anterior myocardial infarction
- Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction. These patients may develop severe hypotension in response to nitrates and generally have a worse prognosis.
- Confirmed with Right sided ECG, Elevation in V4R
- Up to 20% of patients with inferior STEMI will develop significant bradycardia due to second- or third-degree AV block. These patients have an increased in-hospital mortality (>20%).
- ECG findings
- ST elevation in leads II, III and aVF
- Reciprocal ST depression in aVL (± lead I)
- RCA (80%): Elevation in III > II, Reciprocal depression in I
- LCx (20%): Elevation in III = II, No reciprocal depression in I