CASE 01 • FREE SAMPLE
Crushing pain before breakfast
A 58-year-old man has 45 minutes of crushing retrosternal pain, diaphoresis and nausea. BP 104/68 mmHg.
Clinical questions
1. Interpret the ECG systematically.
2. What is the most likely ECG diagnosis?
3. What is the immediate clinical significance?
4. What should be done next?
1. Interpret the ECG systematically.
2. What is the most likely ECG diagnosis?
3. What is the immediate clinical significance?
4. What should be done next?
Anterior STEMI
Systematic interpretation & clinical correlation
Sinus rhythm with acute ST-segment elevation maximal across the anterior precordial leads, with evolving loss of normal R-wave progression and reciprocal inferior ST depression when present. In the appropriate pain syndrome this is an acute anterior occlusion pattern, usually LAD-related; new Q waves or terminal QRS distortion suggest a larger infarct burden.
Sinus rhythm with acute ST-segment elevation maximal across the anterior precordial leads, with evolving loss of normal R-wave progression and reciprocal inferior ST depression when present. In the appropriate pain syndrome this is an acute anterior occlusion pattern, usually LAD-related; new Q waves or terminal QRS distortion suggest a larger infarct burden.
Immediate approach / management
Treat as a time-critical STEMI: activate primary PCI immediately when available within guideline-recommended timelines; do not wait for troponin when the ECG and presentation are diagnostic. Give aspirin, add a P2Y12 inhibitor and anticoagulation according to the reperfusion strategy, high-intensity statin, analgesia, and oxygen only if hypoxaemic. Monitor continuously for shock, ventricular arrhythmia, acute MR/VSD and heart failure.
Treat as a time-critical STEMI: activate primary PCI immediately when available within guideline-recommended timelines; do not wait for troponin when the ECG and presentation are diagnostic. Give aspirin, add a P2Y12 inhibitor and anticoagulation according to the reperfusion strategy, high-intensity statin, analgesia, and oxygen only if hypoxaemic. Monitor continuously for shock, ventricular arrhythmia, acute MR/VSD and heart failure.
High-yield ECG pearl
Extensive anterior ST elevation with hypotension is a high-risk phenotype—early reperfusion and shock surveillance matter more than repeated diagnostic testing.
Extensive anterior ST elevation with hypotension is a high-risk phenotype—early reperfusion and shock surveillance matter more than repeated diagnostic testing.
ECG source/licence: Wikimedia Commons file page.