HPI: 54 yo F with history of CAD s/p 4 previous stents (LAD and first diagonal branch) who presents with abdominal pain, nausea, and vomiting

EKG Interpretation: ST elevation (STE) in anterior, inferior with right ventricular extension, posterior, +/- lateral distributions (only elevation in V6). Reciprocal changes (ST depression) in leads I and aVL.

Cath Report: 100% occlusion of the RCA. 100% occlusion of the posterolateral subdivision. 50% in-stent restenosis of the mid LAD. 50% stenosis of the first diagonal branch

Procedure: Aspiration thrombectomy, PCI of distal and mid RCA x 2

Commentary:

-AHA/ACC for STEMI: Men < 40: 2.5 mm (2.5 small EKG boxes) ST-elevation in V2 or V3, 1 mm in any other lead, Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead, Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

-Leads and Vessel Correlation: V1-V4 are anterior/septal leads correlate with the Left Anterior Descending artery. II, III, and aVF are inferior leads correlate with the Right Coronary artery. I, aVL, V5-V6 are lateral leads correlate with Left Circumflex artery

-Posterior MI: Present if ST depression in the right precordial leads or presence of prominent R-waves and upright T-waves in these same leads. Accompanies 15-20% of STEMIs. Usually associated with inferior or lateral infarctions. Suggestive of a much larger area of myocardial damage. Can consider a posterior EKG to look for STE (V7-V9 in horizontal plane underneath the left scapula)

-Right Ventricular Infarction: Present if the magnitude of ST-segment elevation in lead V1 exceeds the magnitude of ST-segment elevation in lead V2, or if the ST-segment in lead V1 is isoelectric and the ST-segment in lead V2 is significantly depressed, or if the magnitude of ST-segment elevation in lead III exceeds the magnitude of ST-segment elevation in lead II. Associated with approximately 40% of inferior STEMIs. Patients tend to be very preload sensitive from poor RV contractility and nitrates are contraindicated. Consider EKG with right sided leads to look for STE (transfer V3-V6 to right side of chest)