Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Not All Anterior Wall ST Segment Elevations Indicate a Left-sided Lesion.
Grosman, A., D.O, Shittu, M., M.D, Habib, M., M.D
St. Michael’s Medical Center, Newark, New Jersey
Introduction: Electrocardiograms (EKG) are the basis of diagnosing acute
myocardial ischemia. Knowledge of patterns and changes in specific EKG leads
may guide the physician to the coronary vessel being affected. ST segment
elevations on 12-lead electrocardiograms are often used in localizing the culprit
lesion. Although certain patterns are indicative of certain lesions, they are not
always specific. One must also look at other aspects of the EKG, for example,
the rhythm, to further help with the identification of the site of acute ischemia.
Our patient presented with what appeared to be a left-sided lesion, which turned
out to be right-sided.
Case: We present a case of a 51-year-old African American male, with past
medical history significant for hypertension. He complained of chest pain lasting
2 hours prior to presentation at the Emergency Room. Patient described the pain
as sharp, substernal, and radiating to the left chest. The pain began while he
was walking to the train station and grew in intensity as he arrived at the hospital
for evaluation. Associated symptoms included diaphoresis, but he denied
shortness of breath, dizziness, or palpitations. Patient denies prior episodes of
chest pain. His initial electrocardiogram revealed ST segment elevations in leads
V1-V5, with reciprocal ST depressions and T-wave inversions in leads I and aVL.
A repeat EKG also showed a second degree heart block, Mobitz Type 1. Patient
was given sublingual nitroglycerin and IV morphine for pain control, and was
started on a nitroglycerin drip for symptom control. He was also started on the
standard Acute Coronary Syndrome protocol including a loading dose of aspirin,
Plavix, Lipitor, Metoprolol, and Heparin. Code STEMI was activated so the
patient would be taken for immediate cardiac catheterization. Cardiac
catheterization revealed a 100% occlusion in the mid-segment of the right
coronary artery; the left main, left anterior descending artery and the left
circumflex arteries were without disease. He underwent angioplasty with stent
placement of RCA, with subsequent resolution of chest pain and ST changes on
EKG.
Discussion: ST segment elevations in the anterior leads usually suggest leftsided
coronary involvement. However, elevations in V1-V3, as our patient had,
may suggest a right-sided lesion, since the right ventricle is the most anterior
chamber. It is crucial to look at all the aspects and changes on the EKG. Putting
all the information together will help pinpoint the affected lesion with more
accuracy. The rhythm on the EKG may have been the clue to localizing the
culprit lesion, rather than the ST segment elevations alone.