JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Figure 1: Electrocardiogram recorded the day after admission. See text for explication.
DIAGNOSIS
single 50% stenosis in the left circumflex coronary artery. The right coronary artery was clearly the artery causing this infarct, and multiple lesions in the right coronary were stented. After discharge from the hospital, the patient continued to have angina, and four months after discharge she underwent multivessel coronary arterial bypass, which abolished the angina. She was alive 13 years after the infarct described here.
Sinus bradycardia; left atrial enlargement characterized by broad (≥ 0.12s) P waves in leads I, II, aVR, V4-V6; left bundle branch block; ST-segment elevation indicating acute inferior-lateral infarction. Secondary repolarization changes of left bundle branch block are ST-segments and T-waves that are opposite in direction to the major QRS deflections, such as are seen in leads I, III, aVL, aVF, and V1-V5. In leads II and V6, however, the ST segments and T waves are concordant with QRSs, and in the setting of chest pain these primary T-wave changes indicate inferior-lateral injury/ infarction. 1 The day after admission an ECG shows normalization of the QRS/ST-T relationship except in leads III and aVF where predominantly negative QRSs are followed by terminal T-wave inversion (Figure 2). With time the QRS/ST-T relationship will likely normalize completely. Thus, in patients with left bundle branch block the electrocardiographic diagnosis of acute myocardial infarction is often possible. 1 Subacute and especially chronic infarcts, however, are often difficult or impossible to diagnose electrocardiographically. The patient had an intra-aortic balloon pump inserted and underwent coronary arteriography that revealed multiple 70% to 95% stenoses in the right coronary artery, multiple 70% stenoses in the left anterior descending coronary artery, and a
REFERENCES
1. Sgarbossa EB, Pinski SL, Barbagelata A, et al; for the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block.. N Engl J Med 1996;334:481-487.
Mazen M. Kawji, MD, is affiliated with the Heartland Cardiovascular Center, Joliet, Illinois. D. Luke Glancy, MD , is an emeritus professor in the Department of Medicine, LSU Health Sciences Center, New Orleans, Louisiana.
J La State Med Soc VOL 170 MARCH/APRIL 2018 69
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