The following ECG is from a 31 yr old female who is 5 days post-partum she was brought to the Emergency Department following a episode of collapse. On arrival to the Emergency Department she was hypotensive ( Systolic BP ~80 mmHg) with an altered conscious level complaining of chest pain and headache.
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- 60 bpm
- Sinus rhythm
- PR – Normal
- QRS – Normal
- ST Elevation in leads aVR & aVL (
- Upsloping ST depression in leads V2-6
- Maximal in leads V3-4
- Flat ST depression in the inferior leads
- Prominent T waves in leads V2-4
- Features consistent with a De Winter’s pattern
- Suggesting potential LAD pathology
- DDx Demand ischaemia / perfusion mismatch
Given the patients age and medical history broader differentials for shock and ischaemic ECG features would be:
- Endocrine – Sheehan’s Syndrome
What happened ?
The patient was initially treated with iv fluid, analgesia and broad spectrum iv antibiotics ( as initial broad DDx included sepsis). Following review of the initial ECG urgent cardiology input was obtained and an emergent CTPA was performed to exclude PE as a potential cause. On return from a negative CTPA the patient complained of further chest pain, repeat ECG below:
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Clear anterolateral ST elevation and inferior ST depression. The patient was transferred for urgent angiography which showed a 90% mid LAD lesion treated with bioresorbable stent. Subsequent CTPA revealed a coronary artery dissection as the cause for the acute LAD lesion.
Coronary Artery Dissection
This is a rare phenomena occurring in ~4% of all acute MI’s. Approximately 90% of cases occur in females and it accounts for 1/4 of MI’s in the under 50 yr old age group. Recurrence rate is between 13-18%.
There are multiple risk factors including:
- Fibromuscular dysplasia
- Connective tissue disorders
- Systemic inflammatory conditions
- Intense exercise
- Intense emotional stress
- Labour and delivery
- Valsalva-like events
- Sympathomimetic use
References / Further Reading
Life in the Fast Lane
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.