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Two diagnoses from one electrocardiogram
  1. I Beeton,
  2. E Leatham
  1. Cardiology Department, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 5XX, UK
  1. Dr Beeton

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Answers on p xxx. Answers on p 612 .

A 76 year old women presented to casualty with a three hour history of central chest pain radiating to the back and left arm. She was dyspnoeic at rest and four doses of sublingual glycerine trinitrate (GTN) had provided only partial relief. Past medical history included stable angina for a year and deep vein thrombosis. Medication on admission was aspirin, GTN, and isosorbide mononitrate. Cardiorespiratory, abdominal, and neurological examination was normal. Blood pressure was 187/88 mm Hg with a heart rate of 61 beats/min. Full blood count, creatine kinase, and electrolytes were within normal limits. Random cholesterol was 6.8 mmol/l and urea (10.9 mmol/l) and creatinine (141 μmol/l) were raised. An electrocardiogram (ECG) from a previous clinic visit (fig 1) and the admission ECG (fig2) are shown.

Figure 1

Inferior leads of an ECG 18 months before current admission.

Figure 2

Twelve lead ECG taken during chest pain on admission.

Questions

(1) What is the diagnosis?

(2)
What complication of treatment is suggested by the ECG (fig 3) taken the next morning?
(3)
How should this be managed?
Figure 3

Twelve lead ECG taken 18 hours after admission. The patient was not in pain when this ECG was recorded.

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