Emergency Department ECG:
Cardiac Cath Report:
1. LMCA: Short, normal in caliber, distal 30% stenosis, gives rise to the LAD, LCX and a small ramus.
2. LAD: Ostial 100% occluded. (chronic)
3. LCX: Normal in caliber, nondominant, widely patent. Patent OMB1 and OMB2.
4. RCA: 100% ostial occlusion with heavy calcium. Dominant vessel. (Chronic)
1. LIMA to LAD: Patent, goes to small distal apical LAD that is diffusely diseased.
2. SVG to Diagonal: Two tandem stenoses 65% and 75% in the mid body of the graft. Diagonal branch is small but patent.
3. SVG to RCA: 100% occluded in proximal portion, ectatic, heavy thrombus, culprit vessel. Right PDA was noted to be patent once occlusion was treated with PTCA.
Plan: Stent placed to bypass graft occlusion, plan for repeat cath for further intervention
- 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
Right Side ECG: