Question 18.1

A 65-year-old male presents to the Emergency Department (ED) with persisting chest pain for one week, following an acute severe episode that lasted for two hours. His 12-lead ECG, (ECG 1), taken on presentation to ED, is shown below.

a) Describe the ECG changes.

b) What is the most likely diagnosis?

The patient develops worsening chest pain and becomes more tachypnoeic and hypotensive.
c) Give two likely causes for this deterioration.

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College Answer

 Atrial fibrillation with a controlled ventricular response
 Right Bundle Branch Block
 Q-waves V1- V5 and which are wide
 Left axis deviation
 ST elevation anterior and inferior
 ST depression in aVL
 Recent transmural anterior MI with resulting ventricular aneurysm
 Aneurysm rupture
 Septal rupture causing a VSD
 Cardiac tamponade
 Papillary muscle rupture
 Re-infarction
 (Pulmonary embolus)



The ECG above has been stolen shamelessly from Dr Smith's ECG Blog, where it is discussed in glorious detail. Obviously, one would find it difficult to reproduce the exact ECG which the college had in their paper. The one I have stolen is interpreted by Dr Smith in the following fashion:

There is RBBB, but without the usual rSR' in right precordial leads.  [There is some left axis deviation as well, probably a left anterior fascicular (hemi-) block.]  The initial r-wave is gone, so that there are QR-waves (diagnostic of myocardial infarction, whether old or acute).  There is ST elevation (which is never normal in RBBB).  The negative T-wave makes it very unlikely that this acute MI, but it could be either subacute or old.