The WidowMaker

1. The WidowMaker • ECG Rounds • November 21, 2002 • Robbie N Drummond

2. Case 1

3. 60 year old woman • Presents with two week history of worsening fatigue and dyspnea • No discrete chest pain • RF: 20 year history IDDM • 3 ppd cigarette smoker x 40 years • presents in DKA pH 7.2, glucose 34 • cxray shows florid pulmonary edema

6. Admitted CCU • (TnT 0.6 went up to 16.3....CPK 3500) • PTCA undertaken with stent placed in LAD • delicate balance between diuresis and inotropes • remained in CHF with hypotension • despite IABP and BiPAP • after two weeks guarded prognosis still in CCU

7. Killip’s Clinical Complication post MI

8. NB Number one cause of Cardiogenic Shock Anterior MI

9. Case 2

10. 54 year old male from Loon Lake, Saskatchewan... went to Meadow Lake, Saskatchewan • 2 week history of recurring RSCP lasting 20 mins • radiating left shoulder then stopping x many hours • sharp in nature not really relieved with rest coming on while sitting • CRF’s: nil... nonsmoker, normal chol, no DM, no fam hx • previously healthy

12. ECG done while having chest pain

13. Pain subsided and stopped half hour later ECG (No Sx’s)

14. Sent to tertiary care hospital • w/u done • cardiologist decided against intervention • patient drove himself home five hours with on-going chest pain • arrived at Foothills with severe chest pain coming and going... Now 5 days after initial presentation in Meadow Lake

15. ECG in ER at FHH 8/10 RSCP x 45mins

16. One hour later pain mildly diminished with IV nitro... TnT 0.11

19. Interventionalist decided stenting too risky • went for CABG excellent results • sent home post op day 8

20. ECG done while having chest pain

21. Pain subsided and stopped half hour later ECG (No Sx’s)

22. Wellens Syndrome • Described by Wellens 1980’s • A group of ECG signs during the pain-free period of unstable angina • critical stenosis high in the LAD • imminent (mean period 8.5 days) extensive anterior AMI

23. ECG FINDINGS • V2 and V3 diagnostic leads • also found V1 V4 • During ischemic pain positive T waves • During reperfusion negative T wave at an ST-T • angle of 60 - 90 degrees • occurs in the period before infarction

24. Case 3

25. 58 yr old male, no risk factors...one hour chest pain retrosternal, no RF’s, tenderness Left shoulder reproduces pain

26. No further RSCP still shoulder discomfort. Astute EP kept in ER x 8 hrs. TnT came back... 0.41 this ECG:

27. Patient unstable angina Wellen’s Syndrome

29. Non Specific ST-T changes unstable angina

30. 8 Hours Later pain-free Wellens Syndrome

31. 10 Hours later just before catheterization

32. 69-year old man with unstable angina Wellens syndrome findings....pain free

33. Same patient with pain 8 hours later ST elevation V2-V5 as coronary vessel critically narrows

34. Same patient pain-free just before CABG (95% occlusion LAD, 90% occlusion RCA) discharged day 6 post op no complications

35. 99% Occlusion LAD

36. Evolution of ST changes pain-free on admission

37. During pain....ST changes but V1 V2 normalized

38. 12 hours later after completed Anterior MI RBBB and LAH

39. Illustrates how typical monitoring leads do not show Wellens Syndrome changes V1 II vs. V2 V3

40. In Conclusion: • Occlusions of LAD leading to AMI can be deadly • ECG changes in unstable angina preceding MI not always completely helpful • Be aware of Wellens Syndrome • Flipped T waves in anterior leads (V2, V3) during pain-free episodes pathognomonic for LAD lesions

41. En Fins