A 53-year-old female with essential hypertension presented with progressive dyspnea for 1 week. EKG was done to obtain diagnosis.

The 12-lead EKG result is as shown above.

Questions: 

1. Please describe the 12-lead EKG findings

2. What is the most likely diagnosis? 

3. What is the culprit vessel?

4. Please give plan for investigation and management

โดย นายแพทย์ ณัฐพล เกียรติกังวาลชล 

ANSWERs

1. EKG findings:  NSR rate 100, LAD, RBBB, pathologic Q wave at V1-4, STE and TWI at V1-4, III, aVF

2. Diagnosis:  Recent MI (anterior-inferior wall STEMI)

3. Culprit vessel:  Proximal LAD (wrap-around) due to EKG have RBBB with q wave with STE v1-3 (sens 12% spec 100%)

4.1 Investigations

• Trop T, NT-proBNP:  help making diagnosis of dyspnea and tell prognosis 
• CBC, PT, PTT, INR, BUN, Cr, Electrolyte, FBS, HbA1C, Lipid profile:  to obtain baseline lab results
• CXR:  help making diagnosis of dyspnea and to see baseline CXR
• Echocardiogram:  for evaluation of cardiac functions

4.2 Management

1) Acute management

• For progressive dyspnea (suspected acute HF)
  • Decongestion - furosemide 1-2 times of normal use, if furosemide naïve start with 20-40 mg
• For recent STEMI
  • DAPT - ASA loading 150-300 mg then maintenance dose of 75-100 mg/day
  • P2Y12 - Clopidogrel 300 mg then 75 mg/day, or prasugrel 60 mg then 10 mg/day, or ticagrelor 180 mg then 90 mg bid
  • Enoxaparin 1 mg/kg sc q 12 hr                          
  • High intensity statin - atorvastatin 40-80 mg/day, or rosuvastatin 20-40 mg/day
• No role for primary PCI due to onset >48 hours, except presence of ongoing symptoms suggestive of ischemia, unstable hemodynamic, or life-threatening arrhythmia, but angiography should be performed

2) Long term management

• Smoking cessation
• Cardiac rehabilitation program
• Diet control
• Blood pressure, blood sugar, lipid control 

Reference:  Algorithm for ECG identification of the Infarct-Related Artery inAW-STEMI Engelen DJ, Gorgels AP, Cheriex EC et al J Am coll cardio1999; 34:389-95

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