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• W3087968356 abstract "HomeCirculationVol. 142, No. 13A Young Patient With Chest Pain Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessCase ReportPDF/EPUBA Young Patient With Chest Pain R. Gunaseelan, MD, DNB M. Sasikumar, MD N. BalamuruganMD R. GunaseelanR. Gunaseelan R. Gunaseelan, MD, Jawaharlal Institute of Postgraduate Medical Education and Research Emergency Medicine Plot No 1, 2nd Main Road, VOC Street, Dhakshinamoorthy Nagar, Puducherry, India 605009. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1280-209X Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Search for more papers by this author , M. SasikumarM. Sasikumar Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Search for more papers by this author , and N. BalamuruganN. Balamurugan https://orcid.org/0000-0002-3286-7034 Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Search for more papers by this author Originally published28 Sep 2020https://doi.org/10.1161/CIRCULATIONAHA.120.048324Circulation. 2020;142:1299–1301ECG CHALLENGEA 33-year-old man presented to our emergency department with complaints of chest pain for 4 hours. On arrival at our emergency department, the patient was hemodynamically stable. The patient did not have any comorbidities. He was a chronic smoker for 8 years. He denied any cardiac problems in the past. A 12-lead ECG was done, which is shown in Figure 1. What is the diagnosis of this ECG?Download figureDownload PowerPointFigure 1. Twelve-lead ECG at presentation.Please turn the page to read the diagnosis.RESPONSE TO ECG CHALLENGEThe 12-lead ECG of the patient shows a heart rate of 73 beats per minute with negative P waves, negative QRS complexes in lead I, a positive P wave, and a positive QRS complex in lead aVR with poor progression of R wave, indicating dextrocardia.1 The ECG also shows ST segment elevation in leads V1 and aVR. Although the computer interprets the ECG as normal, there were many abnormal findings in it. Hence the clinician should be aware of the potential for erroneous ECG interpretation by computer. The computerized ECG interpretation should be cross-checked and verified by a physician.2 Traditionally, ST segment elevation in leads aVR and V1 usually signifies occlusion in the proximal LAD or left main disease. On account of dextrocardia, the aforementioned lead orientation and its interpretation do not correlate with the interpretation of a standard 12-lead ECG. In this case, lead I will be flipped as the wave of depolarization travels from left to right. Furthermore, lead aVR will mimic lead aVL and vice versa.Therefore, to interpret the ECG of this patient, we should take a right-sided ECG with the chest leads placed as a mirror image of the lead placement for a normal 12-lead ECG given that the heart of the patient is on the right side of the chest. That is, lead V1 should be placed in V2 and V2 in V1, and leads V3 to V6 should be placed in V3R to V6R. In addition, the limb leads should be reversed.3 An ECG taken with the aforementioned changes is shown in Figure 2.Download figureDownload PowerPointFigure 2. Mirror-image ECG.ECG taken with right and left limb leads reversed and chest leads placed on the right side: a mirror image to the traditional 12-lead ECG.This ECG shows a heart rate of 72 beats per minute with ST segment elevation in lead I and aVL and from leads V1 through V6 with T wave inversion in leads I, aVL, and V2 to V6, suggesting an extensive anterolateral wall myocardial infarction.The patient was admitted for primary percutaneous intervention. During coronary angiography, total occlusion in the proximal LAD (Figure 3) was found, which was successfully reperfused with thrombosuction, and a drug eluting stent was placed.Download figureDownload PowerPointFigure 3. Angiography.Shows total occlusion of proximal LAD in coronary angiography. This image is a mirror image of the image acquired in Right Anterior Oblique (RAO) Caudal 45° projection. LAD indicates left anterior descending artery.Important Learning Points From This CaseDextrocardia can result in difficulty in interpreting a standard 12-lead ECG. The limb leads and chest leads should be reversed to interpret it correctly in such cases. Anterior wall myocardial infarction in a patient with dextrocardia might not be readily appreciable in a standard 12-lead ECG. Furthermore, in a patient with dextrocardia, ST elevation in leads V1 and aVR (when taken in the standard 12-lead ECG) will be equivalent to ST elevation in leads V2 and aVL, which would suggest anterior wall myocardial infarction. Therefore, it is crucial to always verify the diagnosis of the computer by interpreting the ECG on your own.AcknowledgmentsWe acknowledge the constant support and motivation given by our Head of the Department, Prof Dr Vivekanandan Pillai, MD. You are a true inspiration to all of us, sir.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circR. Gunaseelan, MD, Jawaharlal Institute of Postgraduate Medical Education and Research Emergency Medicine Plot No 1, 2nd Main Road, VOC Street, Dhakshinamoorthy Nagar, Puducherry, India 605009. Email [email protected]comReferences1. Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice E-Book: Adult and Pediatric. Elsevier Health Sciences2008Google Scholar2. Mark Estes NA. Computerized interpretation of ECGs.Circulation Arrhythm Electrophysiol. 2013; 6:2–4. doi: 10.1161/CIRCEP.111.000097LinkGoogle Scholar3. Reiffel JA. ECG response: can you make the correct morphology, pathology, and rhythm diagnoses?Circulation. 2016; 134:567–569. doi: 10.1161/CIRCULATIONAHA.116.024356LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails September 29, 2020Vol 142, Issue 13Article InformationMetrics Download: 705 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.048324PMID: 32986481 Originally publishedSeptember 28, 2020 PDF download SubjectsCongenital Heart DiseaseStentAngiographyElectrocardiology (ECG)Percutaneous Coronary Intervention" @default.
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