The LAdy and her EKG

68yo F hx HTN, GERD, MI presenting with substernal burning pain since yesterday. took her prilosec with good relief of her symptoms. ran out of her prilosec today, so pain has persisted. worse with exertion. non-radiating. associated with diaphoresis. denies sob, nausea, vomitting, or other symptoms. states she's CP free currently. states her prior MI was 'silent' and didn't know when she had it. 

PMHx: htn, gerd, mi, 'enlarged heart'

FHx -neg, SHx -no tobacco, ETOh, drugs. No prior Sg. 

Last cardiac stress 2yrs ago - ?borderline. No prior cardiac cath. 

PE: afebrile, HR@115, BP@148/68, RR@12, 98% on RA; 

  CV: no murmurs, 

  Pulm - no wheezing or rales, good bs. No overt signs of fluid overload. 

EKG: wat do u see?

CXR: enlarged heart, no pulmonary edema. 

Labs: Trop 0.12. (cbc, bmp otherwise normal)

Outcome: Pt was CP free. Given asa. Cardiology c/s. Transferred to CCU. Started on heparin and integrillin gtt. Planned cath for the next day. *Next day, trop peaked at 0.4*

Teaching point: ST elevation in aVR.
ST Elevation of more than 1mm in aVR in the setting of Acute Coronary syndrome is:

• associated with left mainstem (LMCA) disease and 3 vessel disease.
• suggests urgent angiography is necessary.
• associated with an increase in mortality.
• Probably not an indication for emergent angiography @ 3am unless the patient is not settling with standard medical therapy.

LMCA stenosis is bad - 70 % mortality without surgery / PTCA

In summary, if you see an EKG with ischemic changes, ALWAYS LOOK AT aVR for ST Elevation!!!!!!!!!! This means baddness!

Listen to Dr. Amal Mattu talk abt STE in aVR HERE

See reference HERE, visit another blog with similar presentation and cool EKG HERE