Your patient called you last night and told you that she was having Substernal Chest Pain 10/10 for a few hours with "drenching sweats and nausea". You, being the good doctor that you are, instructed her to go to the ER. You have no idea what happened last night because your colleague was on call. He copied all the EKG's and left them in your mail box at the office because he thought you would like to know what happened. Here is the series of EKG's, the first one is already after a few hours of Chest Pain. What is your interpretation?

EKG #1 5:00 pm

Click Here for better Image of EKG#1

So Starting with the first EKG in the series. The First EKG was catching the patient in a run of Monomorphic Non-Sustained V-Tach which is very clear in lead I. As you can see, she did not need to be shocked as she spontaneously converted to an irregular rhythm with no P-waves seen in the rhythm strip, which is atrial fibrillation. What is very concerning is the ST-Elevations seen in AVF and the rhythm strip (lead II) but because the first half of the EKG is distorted by the V-Tach, we need a repeat to localize it, and to know if it is real. She also has two PVC at the end of the rhythm strip, the 3rd to last QRS and the last one. The QRS is also wide at .12 seconds but because I, II and III are distorted we cant really comment on what kind of block if any is present. SO WE NEED A REPEAT.

The next EKG is the immediate repeat to the first. Now her rhythm is Atrial Fibrillation, (knowing from the previous rhythm strip on EKG#1) with Ventricular Bigeminy (which is a PVC after every "normally" conducted beat). What is also even more clear now on the EKG is the ST elevations in II / III / AVF with the max ST elevation being 7 mm in III, representing an ACUTE INFERIOR ST ELEVATION MI. She also still has the wide complex at .12 seconds and no criteria are met for any bundle branch blocks, so we can safely say there is a Non-Specific Intra ventricular Conduction Delay. Most likely secondarily to the massive MI she is having. What we can also infer is that the Non-Sustained Ventricular Tachycardia is also secondary to the ischemia and infarction as people actively infarcting are at very high risk for these type of arrhythmias.

Now one hour later EKG #3. Similar diagnosis are present as on EKG #3, however there are some differences. The Bigeminy is resolved. What is more interesting is to note the ST Elevation in II,III, and AVF are now only 3 mm, and the Q waves in the same leads are now larger than in EKG #2. This tells us that the acute event is now nearing the end, instead of the other way around. This is sometimes called "Q-ing OUt". The new Q waves also tell us that she lost myocardium from the event. That is why when you see q waves you say age indeterminate infarct because it is not active, but represents old lost muscle. So we are actually seeing the Q waves be created.

The next day's EKG is #4. Again the similar diagnosis as on EKG#2 and #3, but there are some changes. Notice the Q waves have gotten even larger in lead III and the ST-elevations are almost totally back to baseline. This again tells us that the acute event is essentially over, and that she has lost a significant amount of myocardium by the huge q waves seen in lead III. She also has new U waves seen in the Precordial leads, v1-v5 which are common in hypokalemia, which she did develop.

So all 4 EKG's show the series of changes in an acute MI and the development of q waves and the arrhythmias people are susceptible to in an ACute MI. A great series of EKG's!