August 24, 2013

ECG: Left Main Coronary Artery Disease

42 years old lady with known case of skin vitiligo, stroke with right hemiplegic unsure of type and hypertension was referred for right elbow abscess. She otherwise denied typical chest pain, no nausea and vomiting, diaphoresis or syncopal attack

On examination, vital signs are normal. heart S1S2 with PSM at mitral region grade 4, no basal crepitation, no raised JVP or ankle edema.

ECG taken shows generalized down sloping ST depression with ST Elevation >1 mm at lead aVR

CXR shows minimal cardiomegally with no APO changes.

Patient remain asymptomatic and repeated ECG no dynamic changes.


Generalized ST depression with ST elevation at the lead AVR is indicative of left main coronary artery disease and not necessarily means ischemia as patient do not have typical chest pain.

Other differential such as systemic illness like anemia or electrolyte imbalance should be seek. Serial cardiac enzyme would be very useful to exclude myocardial ischemia.


  1. LV strain pattern possible x dr?

  2. I have consulted two emergency physician with one of them is sub in cardio.. this is their is not revealed because this consultation is made just for learning purpose and not for patient management as this is retrospective consultation

    1) Dr A
    Left coronary disease. or systemic illness (hyo K / anemia)

    2) Prof R
    Asymptomatic, hypertensive, cardiomegaly, ECG- SR, LVH, ST depression at >8 leads, ST up at aVR. My impression is asymptomatic triple vessels disease. If patient presents with chest pain then i consider LMS occlusion @ostial LAD occlusion and? ? Acute PE. Silent MI occurs in 20% of population. If silent MI is strongly considered, MONICA criteria needs to be fullfilled.



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