ECG of the Week 27th October 2021 Interpretation

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A 81 year old male presents to a regional emergency department, 4 hours away from a cath lab, complaining of chest pain. Below is the patients ECG:

Describe and Interpret the ECG

List the contraindications for thrombolysis

Answer:

Rate: 66 beats/min

Rhythm: normal sinus rhythm

Axis: normal axis

Intervals

  • PR 160ms
  • QRS 130ms
  • QTc 430ms

Additional:

Left Bundle Branch Block morphology

Concordant ST elevation of 1-2mm in III and aVF, ST depression V2 and ST elevation V4

The above ECG shows a LBBB, with evidence of STEMI equivalent criteria ie Sgarbossa criteria

  • Concordant ST elevation >1mm in > 1 lead
  • Concordant ST depression 1mm in V2
  • Discordant ST elevation >25% V4

Modified Sgarbossa Cirteria:

  • Concordant STE ≥ 1 mm in any lead
  • Concordant STD ≥ 1 mm in V1, V2, or V3
  • Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave

As this patient is in a regional area, with no cath lab facilities, thrombolysis needs to be considered. The following are contraindications to thrombolysis:

Absolute contraindications

  • aortic dissection
  • new neurological signs
  • significant head of facial trauma in previous 3 months
  • any previous intracranial haemorrhage
  • ischaemic stroke within 3 months
  • known intracranial vascular malformation
  • known malignant intracranial neoplasm (primary or metastatic)
  • acute pericarditis
  • active bleeding (except menstruation)

Relative Contraindications

  • Anticoagulation – risk of bleeding relates to INR
  • Non compressible vascular punctures eg transvenous pacing, CVC line insertion
  • Hypertension – delay thrombolysis until systolic BP < 180 mmHg or diastolic BP < 110 mmHg
  • CPR
  • Surgery -major surgery in previous 3 weeks or CNS surgery in previous 2 months
  • Gastrointestinal or urinary haemorrhage in previous 4 weeks or active peptic ulcer
  • Malignancy
  • Menstruation – usually safe as menstrual bleeding is due to endometrial vasoconstriction
  • Pregnancy – TPA – classified as category B1

Odds ratio of patient having a ICH post thrombolysis increases if the patient is:

  • >75 years
  • <70 KG
  • Uncontrolled hypertension
  • Prior stroke of any type