A man in his early sixties with palpitations

Case submitted and written by James Tavornwattana, edits by Pendell Meyers and Steve SmithA male in his 60s with diabetes presented to the ED with one hour of palpitations associated with a 30 min episode of throat burning sensation when he woke up this morning. He denied chest pain, shortness of breath, or lightheadedness.Initial ECG (0 hr):What do you think?Interpretation:Atrial fibrillation with rapid ventricular responseST depression that is maximal in V2-V4, also with lesser STD in V5, I, aVL, II and aVF. With multi-lead STD, there is of course STE in aVR.This pattern and location of STD (maximal in V1-V4) is indicative of focal, posterior transmural infarction, with the most likely etiology being Occlusion MI. Notably, this is NOT the pattern of diffuse supply/demand mismatch, in which the STD is maximal in V4-6 and lead II.There are other possibilities, such as a " type II STEMI " , for example: acutely increased demand (in this case due to rapid ventricular response) on an already chronically stenosed LCX, resulting in massive supply/demand mismatch and transmural ischemia. But this would be a diagnosis of exclusion compared to the possibility of OMI, given the diagnostic ECG.Back to the case:The clinicians thought the STD represented demand ischemia from AF with RVR. The patient was given magnesium, diltiazem, and fluids with improvement in ventricular rate. Unfortunately there is no ECG recorded soon after rate control. This would ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs