LVH with ST/T Changes and Streptokinase

Report:

Sinus rhythm 72/min

Borderline left atrial abnormality

Borderline left axis deviation –30o

Left ventricular hypertrophy with ST/T changes

ST/T changes also consistent with ischæmia

Intraventricular conduction delay (IVCD)

QRS 0.12”

Comment:

The IVCD is probably an incomplete LBBB.

There is no direct evidence of the known previous infarction but the T waves are narrow and deeply inverted; their inversion is also concordant with the terminal QRS in Lead 2 and V2, supporting ischæmia or infarction additional to LVH. The modest ST segment elevation in V1-2 can be put down to LVH alone.

These changes have evolved from a simpler LVH with ST/T changes present on admission, a day earlier (112a). This showed junctional rhythm with interestingly prominent PTF in V1 and apical thrust artefact in V6. There was more ST segment depression and less T inversion. More or less ischæmia? The question has to be answered on other grounds.

This should not have been an ECG for immediate streptokinase infusion. On review, the patient had both chest and abdominal pain in the original hospital. The decision to use thrombolysis must have been based on the ECG alone. Its lesson should be obvious.

Oddly enough, the patient survived, albeit on hæmodialysis for several weeks. The reason for survival is undoubtedly the rupture forming an aorto-caval fistula (an inch-wide communication at surgery), rather than free bleeding retroperitonealy or elsewhere.