An elderly man with sudden cardiogenic shock, diffuse ST depressions, and STE in aVR

Written by Pendell Meyers84 yo M with history of a “valve problem” presented for sudden onset chest pain and trouble breathing while eating lunch.He was sitting bolt upright, diaphoretic, tachypneic, with bilateral crackles. Although his BP was 126/84, he was in acute cardiogenic shock.Here is his initial ECG:Sinus tach with occasional PACs. Relatively normal QRS complex with diffuse significant ST depression including leads V2-V6, I, aVL, II, III, and aVF, with ST elevation in aVR. The vector of ST depression is maximal in leads V5 and II, consistent with diffuse subendocardial ischemia. There is no evidence of any single vessel OMI (Occlusion MI). This is not consistent with posterior OMI, which would have ST depression maximal in V2-V4 usually without diffuse ST depression.The differential for acute chest pain and cardiogenic shock without evidence of OMI on ECG includes:(still) OMI - the ECG is not perfectly sensitive for OMI3 Vessel disease with superimposed non-occlusive ACSNon-occlusive ACS of any major vessel, including left mainAcute aortic stenosis or other acute severe valvular abnormalityAny other cause of acute severe supply-demand mismatchAny combination of the aboveThe ECG does not differentiate the above etiologies, it simply signifies that there is severe diffuse global supply-demand mismatch, whatever the etiology.Bedside ultrasound revealed significant LVH and an extremely bright, dense, nearly non-moving aortic valve (video not available).He went to th...

Source: Dr. Smith's ECG Blog - October 31, 2018 Category: Cardiology Authors: Pendell Source Type: blogs