An elderly woman presented to the ED with a rash...

An elderly woman presented to the ED with a rash and shortness of breath thought to be due to a new topical medication/cream she was using.

Afebrile, Tachycardia with tachypnea.

Exam: Mild distress, crackles to both lung fields.

During her work-up she complained of increasing shortness of breath and chest pain. Work-up below:

ECG:

ST depressions in the inferior leads. STE in AVr, V2, and V3.

CXR: Bilateral interstitial opacities concerning for pulmonary edema.

Echo:

Here the septum is akinetic and makes the RV appear hyperdynamic.

In this PSX view the septum and the anterior wall are hypokinetic.

Notice in this A4C view the septum and portion of the apex are hypokinetic. The patient was transferred, emergent PCI performed showing 100% LAD occlusion.

You can review your coronary artery anatomy and distribution on echo with the graphic above. Notice there is some overlap with the RCA and LAD at the septum.

Shalbaf, Ahmad & Behnam, Hamid & Alizade-Sani, Zahra & Shojaeifard, Maryam. (2013). Automatic Classification of Left Ventricular Regional Wall Motion Abnormalities in Echocardiography Images Using Nonrigid Image Registration. Journal of digital imaging : the official journal of the Society for Computer Applications in Radiology. 26. 10.1007/s10278-012-9543-x.

Learning points:

-It is helpful to know and review the coronary artery distributions on BOTH ECG and Echo.

-Keep in mind that there is overlap.

-In ECGs that are borderline and not conclusively STEMIs, bedside echocardiography can sway you and possibly your cardiologist if they are not convinced the patient needs cardiac catheterization.