• ST segment elevation
• acute myocardial infarction

An 82 year old hypertensive woman presented to the emergency department with a two hour history of retrosternal chest pain. She had no previous history of angina or myocardial infarction. Her initial 12 lead electrocardiogram (ECG) showed massive “tombstone” ST elevation in the anterolateral leads (fig 1) and she was thrombolysed with tenecteplase. She developed torsades de pointes during reperfusion but otherwise made an unremarkable recovery (fig 2). She had a troponin T rise of 6.5 ng/l.

Tombstone ST elevation is an unusual morphological ECG appearance of acute myocardial infarction. The ST segment is convexed upwards and the peak of the convexed ST segment is often higher than the preceding R wave, which is less than 0.04 s and small in amplitude. This type of tombstone pattern is associated with reperfusion polymorphous ventricular tachyarrhythmias¹ and is thought to represent extensive and rapid myocardial damage after the ischaemic episode. At coronary angiography, patients with tombstoning are likely to have high grade stenosis of the proximal left anterior descending artery.²

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Figure 1

ECG before thrombolysis.

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Figure 2

ECG after thrombolysis.