ECG Puzzler

A regular feature of the American Journal of Critical Care, the ECG Puzzler addresses electrocardiogram (ECG) interpretation for
clinical practice. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click
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PREDICTIVE PATTERN FOR ACUTE MYOCARDIAL INFARCTION

By Teri M. Kozik, RN, PhD, CNS, CCRN, Salah S. Al-Zaiti, RN, PhD, CRNP, CCRN, Mary G. Carey, RN, CNS, PhD,
and Michele M. Pelter, RN, PhD
Scenario: This 12-lead electrocardiogram (ECG) pain. His blood pressure was 110/70 mm Hg, heart
was obtained from a 64-year-old man who was evalu- rate 92/min, respiratory rate 18/min, and body tem-
ated in the emergency department after a 10-minute perature 36.6C. He is a smoker and has a history of
episode of chest pain accompanied by diaphoresis hypertension and hyperlipidemia for which he takes
and left arm pain while playing with his dog. He had a calcium channel blocker and a statin. All of his lab-
noticed similar episodes in the past couple of weeks. oratory test results were normal, including the tropo-
In triage when this ECG was obtained, he had no chest nin I level.

I aVR V1 V4

aVL V2 V5
II

III aVF V3 V6

II

Device: 44837 Speed: 25 mm/sec Limb: 10 mm/mV Chest: 10 mm/mV

Interpretation Questions:
1. Is the ECG properly calibrated (10 mm) and are leads properly placed? R Yes RNo R NA
If no, interpret cautiously.
2. Is this a sinus rhythm (one P wave preceding every QRS complex)? R Yes RNo R NA
If no, check for number of P waves in relation to QRS complexes.
3. Is the heart rate (R-R interval) normal (60-100/min)? R Yes RNo R NA
If no, check for supraventricular or ventricular arrhythmias.
4. Is the QRS complex narrow (duration 110 milliseconds [ms] in V1)? R Yes RNo R NA
If no, check for bundle branch blocks (BBBs), pacing, or ventricular arrhythmia.
5. Is the ST segment deviated ( 2 mm in V2-V3, or 1 mm in other leads)? R Yes RNo R NA
If yes, check for similar deviations in contiguous cardiac territories.
6. Is the T wave inverted in relation to the QRS (> 5 mm)? R Yes RNo R NA
If yes, check for ST deviation or conduction abnormalities.
7. Is the QT interval lengthened (> 450 ms [men] or > 470 ms [women])? R Yes RNo R NA
If yes, check for ventricular arrhythmias or left ventricular hypertrophy.
8. Is R- or S-wave amplitude enlarged (S wave V1 + R wave V5 > 35 mm)? R Yes RNo R NA
If yes, check for axis deviation or other chamber hypertrophy criteria.

Teri M. Kozik is a nurse researcher at St Josephs Medical Center, Stockton, California. Salah S. Al-Zaiti is an assistant professor at the
Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Mary G. Carey is associate director for clinical
nursing research, Strong Memorial Hospital, Rochester, New York. Michele M. Pelter is an assistant professor at the the Department of
Physiological Nursing at University of California, San Francisco, California.

2017 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2017631

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2017, Volume 26, No. 3 257
 I aVR V1 V4

aVL V2 V5
II

III aVF V3 V6

II

Device: 44837 Speed: 25 mm/sec Limb: 10 mm/mV Chest: 10 mm/mV

Answers:
1. Yes, proper gain indicated (10 mm/mV).
2. Yes, there is one P wave per QRS complex.
3. Yes, the heart rate is 92/min.
4. Yes, the QRS complex is narrow.
5. No, the ST segments are not deviated.
6. Yes, the T wave is inverted in leads III, aVF, and V1 through V4.
7. Yes, the QTc is 476 ms.
8. Yes, evidence of left ventricular hypertrophy (S wave in V1 + R wave in V5 = 38 mm) is present.

Interpretation angina (symptoms at rest) and specic precordial T-wave

Sinus rhythm with left ventricular hypertrophy (LVH). changes later had a large anterior myocardial infarction
The deep T-wave inversions in leads V1 to V3 and biphasic (MI). These ECG T-wave changes suggest severe stenosis
T wave in lead V4 are suggestive of Wellens syndrome. of the proximal portion of the left anterior descending
T-wave inversion is commonly associated with LVH, which (LAD) coronary artery and are thought to represent reper-
typically is seen in multiple and in some cases all ECG fusion of the myocardium. If left untreated, an acute ante-
leads, whereas T-wave inversion associated with Wellens rior wall MI develops within a few weeks in many patients
syndrome is localized to the anterior wall region. with these typical signs and symptoms. ECGs taken during
an episode of pain in this population often show upright
Rationale T waves and ST-segment deviation (elevation or depression).
This patients reported intermittent symptoms over the Clinicians must recognize this ECG pattern promptly
course of weeks, along with the ECG, are highly suggestive and refer patients for immediate care because this syndrome
of Wellens syndrome. The ECG patterns that characterize is a preinfarction phase of coronary artery disease that can
Wellens syndrome are deeply inverted or biphasic T waves lead to infarction of the left ventricle. The recommended
in the precordial leads (especially V2 and V3), often observed treatment for such patients is urgent coronary angiography
when no current symptoms are apparent. Other ndings and subsequent treatment with either percutaneous coronary
can include normal to minimal elevation of cardiac enzyme intervention or bypass surgery to prevent an extensive MI.
levels, absence of precordial Q waves, no loss of R waves, Cardiac catheterization of the patient later that day showed
and marginal (< 1 mm), if any, ST-segment elevation. 95% occlusion of the proximal LAD artery, which was treated
with a drug-eluting stent. His echocardiogram the following
Management morning showed a normal ejection fraction, so he was dis-
Wellens syndrome was rst described in 1982 by charged home on a standard-of-care pharmacological regi-
Hein J. J. Wellens after a subset of patients with unstable men with smoking cessation and dietary counseling.

258 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2017, Volume 26, No. 3 www.ajcconline.org
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