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(Circulation. 1998;97:2274-2275.)
© 1998 American Heart Association, Inc.

Images in Cardiovascular Medicine

Electrocardiographic Diagnosis of Acute Myocardial Infarction During Ventricular Pacing

Roland R. Brandt, MD; Stephen C. Hammill, MD; ; Stuart T. Higano, MD

From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minn.

Correspondence to Stuart T. Higano, MD, Mayo Clinic and Foundation, Division of Cardiovascular Diseases, 200 First St SW, Rochester, MN 55905. E-mail higano@mayo.edu

A 51-year-old man presented to the emergency room with a 30-minute history of sudden, severe, crushing retrosternal chest discomfort with radiation to both shoulders. Cardiac risk factors included a history of tobacco abuse and a family history of premature coronary atherosclerosis. A single-chamber pacemaker programmed to the VVI mode had been implanted 12 years earlier for a bradycardia-tachycardia syndrome, and the patient was considered pacemaker dependent. Physical examination was unremarkable. A previous baseline ECG (Figure 1) was compared with the ECG on admission (Figure 2) that showed significant ST-T–segment changes in the interim. The patient underwent emergency coronary angiography that revealed an occluded proximal left circumflex coronary artery with minimal other disease (Figure 3). Primary percutaneous coronary angioplasty was performed, and the remainder of the hospital course was uneventful.

View larger version (76K): [in this window] [in a new window]   Figure 1. Baseline ECG showing ventricular pacing at 69 pulses per minute, with typical repolarization abnormalities and underlying atrial fibrillation.

View larger version (91K): [in this window] [in a new window]   Figure 2. ECG during acute myocardial infarction, showing ventricular pacing at 69 pulses per minute and underlying atrial fibrillation with new ST-T–wave changes compared with baseline ECG (Figure 1). ST-segment depression of 2 mm in leads V2 and V3 and ST-segment elevation of 1 mm in leads V5 and V6 are now present. ST-T–segment changes are concordant (in same direction) with QRS complex, a finding atypical for pacing-induced repolarization.

View larger version (133K): [in this window] [in a new window]   Figure 3. Coronary angiography (right anterior oblique view with caudal angulation) during acute myocardial infarction showing total occlusion of proximal left circumflex artery.

The ECG is the most . . . [Full Text of this Article]