Hyperacute Anterior Infarction

Report:

Sinus rhythm 66/min

Acute anterior infarction

Comment:

The term hyperacute refers to increase in T wave height at a very early stage of myocardial infarction. The waves need not be large. As Goldberger put it6, “the amplitude of hyperacute T waves, contrary to the connotations of the name, need not be markedly increased”. Nevertheless, in clinical practice, the term is rarely used unless the T waves are prominent.

The ST segments may be also elevated, as here, or normal, or even depressed (with “de Winter T waves”7. The reciprocal changes may or may not be present.

R waves are also large in the anteroseptal leads, with early transition suggesting, in association with upright T waves, isolated (“true”) posterior infarction. This is impossible to exclude, electrocardiographically; what is against it is the absence of inferior MI seen in 90% of posterior infarcts and the lack of RV1 dominance seen in most posterior infarcts.

Increase in R waves’ height may represent an even earlier stage of infarction than hyperacute T waves8. They are certainly bigger than in the normalised trace taken after successful PTCA of a long mid-LAD artery segment (Fig 10a). On the other hand, some loss of R wave height could have resulted from the infarction itself, its only ECG sign at this stage.

The next two recordings show an AIVR 85/min preceding reperfusion (Fig 10b) and evolving T wave changes the next day (Fig 10c). The latter, unsurprisingly, mimic the Wellens’ warning pattern of LAD disease.