ECG Case 003

This is fairly simple straightforward case but it reinforced something for me.

4am standby call for a STEMI. At 4am. Was he shovelling snow at 4am?


Chest pain for 9 hours.

[peekaboo_link name=”Diagnosis”]Diagnosis[/peekaboo_link][peekaboo_content name=”Diagnosis”]

There’s ST elevation in a lot of leads – meaning that it would have to be a really funky anatomic variant to explain such a huge territory of infarction. Either that or multiple acute occlusions in different vessels. That’s a give away.

It’s pretty damn saddle shaped. That’s a give away too.

There’s ST depression in aVR. Hmmm.

That was what got me. Because Amal Mattu is such a good teacher I have a whole differential for ST elevation. And I remember that if there’s ST depression on an ECG with ST elevation then I’ve made my diagnosis – it’s a STEMI.

And at 4am  that’s what you remember and what makes you a little uncomfortable calling this as straightforward pericarditis.

You ring cardiology and tell them you think it was just pericarditis but are a little concerned by the ST depression. They come and see the patient and with no wall motion abnormality on echo and no evolution on serial ECGs they call it as pericarditis too.

In pericarditis you’re allowed ST depression in V1 and aVR but nowhere else.

So did Dr Mattu teach us wrong?

Of course not. In fact I was there when he told me at ICEM 2012. I even tweeted it. So much for long term memory…

Lesson learned.

Check out the full video by Amal below:


Blackouts and syncope.

I gave a talk to our registrars recently on falls and blackouts. Such a colossal topic in 45 minutes was never gonna cover all the material so I ended up focusing on the ECG in syncope and falls assessment in the elderly.

In the spirit of FOAM (Free Open-Access Meducation) I figured all the work I’d already done was worth spreading around to more than the 8 people that were there.

So here it is in video form…

Credits to:

Apologies to the international listeners if I get a bit speedy with the old talking.

As usual, I’d love to hear any comments or corrections you might have.