What is the management for a patient with an electrocardiogram (EKG) showing inverted T waves in lead aVL and ST elevation in lead V2, suggestive of acute coronary syndrome?

Management of EKG with Inverted T Waves in aVL and ST Elevation in V2

This patient requires immediate emergency department evaluation for acute coronary syndrome (ACS), with ST elevation in V2 indicating possible anterior wall myocardial infarction requiring urgent reperfusion therapy within 120 minutes. 1, 2

Immediate Actions (Within 10 Minutes)

The following steps must be completed immediately upon presentation 1, 3:

• Obtain a 12-lead ECG immediately and compare with any prior tracings to identify new changes 1
• Administer aspirin 162-325 mg (unless contraindicated) 1, 3
• Establish IV access and check vital signs with oxygen saturation 3
• Draw initial high-sensitivity cardiac troponin (preferred biomarker) 1, 2
• Administer sublingual nitroglycerin if chest discomfort is ongoing 3
• Initiate continuous ECG monitoring to detect life-threatening arrhythmias 1

Risk Stratification Based on ECG Pattern

ST Elevation in V2

ST-segment elevation signifies complete or near-complete coronary artery occlusion and requires immediate reperfusion therapy. 1 This represented 42% of ACS cases in the European Heart Survey and mandates urgent intervention 1.

The presence of ST elevation in V2 specifically suggests:

• Anterior wall involvement with likely left anterior descending (LAD) coronary artery occlusion 1, 2
• High risk for extensive myocardial damage if reperfusion is delayed 1, 2

T-Wave Inversion in aVL

T-wave inversion in aVL provides additional diagnostic information 1:

• When the LCx (left circumflex) is occluded, the ST segment may be isoelectric or elevated in leads I and aVL, making isolated T-wave inversion in aVL less typical for LCx occlusion 1
• This pattern combined with anterior ST elevation suggests LAD territory involvement with possible lateral extension 1, 3
• T-wave inversion ≥1 mm in leads with dominant R waves places patients at intermediate-to-high likelihood for ACS 3

Reperfusion Strategy

Primary PCI (Preferred)

Primary percutaneous coronary intervention (PCI) within 120 minutes of presentation reduces mortality from 9% to 7%. 2 This is the preferred reperfusion strategy for STEMI 1, 2.

The patient should be transferred immediately to the cardiac catheterization laboratory for 1:

• Coronary angiography to identify the culprit lesion
• Immediate revascularization with PCI (with or without stenting)

Fibrinolytic Therapy (If PCI Unavailable)

If PCI within 120 minutes is not possible, administer fibrinolytic therapy 2:

• For patients <75 years: Full-dose alteplase, reteplase, or tenecteplase 2
• For patients ≥75 years: Half-dose of the above agents, or full-dose streptokinase if cost is a consideration 2
• Transfer to PCI-capable facility within 24 hours after fibrinolysis 2

Adjunctive Medical Therapy

Antiplatelet Therapy

Dual antiplatelet therapy should be initiated 1, 4:

• Aspirin 75-325 mg daily (already given as loading dose) 1
• Clopidogrel 300 mg loading dose, then 75 mg daily 1, 4
  • Omit clopidogrel if CABG is likely within 5 days 1
  • Consider higher loading dose (600 mg) in some protocols 4

Anticoagulation

Administer low-molecular-weight heparin (LMWH) or unfractionated heparin immediately 1

Additional Therapies

• Beta-blockers unless contraindicated (heart failure, bradycardia, hypotension) 1
• Nitrates (oral or intravenous) for persistent or recurrent chest pain 1
• Statins should be initiated 2
• GPIIb/IIIa inhibitors may be considered in high-risk patients, particularly if undergoing PCI 1

Serial Troponin Protocol

Obtain serial troponin measurements at 0,1-2, and 3-6 hours to distinguish STEMI from NSTEMI and quantify myocardial damage 1, 5. However, do not wait for troponin results to initiate reperfusion treatment in the presence of ST elevation 1.

Critical Differential Diagnoses

While ST elevation in V2 strongly suggests anterior STEMI, consider these alternative diagnoses 3, 5, 6, 7:

• Takotsubo (stress) cardiomyopathy: Presents with anterior ST elevation mimicking LAD occlusion, but with minimal troponin elevation, absence of obstructive coronary disease, and apical ballooning on imaging 7
• Acute myocarditis: Can present with ST elevation and troponin elevation but typically has more diffuse ECG changes 6
• Left ventricular hypertrophy: Can cause ST-T wave abnormalities, but comparison with prior ECGs is essential 1

Imaging Strategy

Immediate Echocardiography

Perform urgent echocardiography to assess 1, 5:

• Regional wall motion abnormalities (occur within seconds of coronary occlusion) 1
• Left ventricular ejection fraction (LVEF) 1, 7
• Mechanical complications (severe mitral regurgitation, ventricular septal defect) 1
• Alternative diagnoses (aortic dissection, pericardial effusion, pulmonary embolism) 1

Wall motion abnormalities are not specific for acute MI and may represent ischemia or old infarction, but their absence effectively excludes major myocardial infarction 1.

High-Risk Features Requiring Immediate Intervention

This patient has multiple high-risk features 1, 3, 5:

• ST elevation indicating ongoing transmural ischemia 1
• Anterior territory involvement (V2) suggesting large amount of myocardium at risk 1, 3
• Multi-lead involvement (aVL + V2) suggesting extensive ischemia 3, 5

Patients with ongoing myocardial ischemia characterized by ST-segment elevation are at risk for developing cardiogenic shock and malignant ventricular arrhythmias, making immediate coronary angiography and revascularization mandatory. 1

Common Pitfalls to Avoid

• Do not dismiss ST elevation as "early repolarization" without careful comparison to prior ECGs and clinical context 1, 3
• Do not delay reperfusion therapy waiting for troponin results 1
• Do not rely on a single negative troponin to exclude MI, as serial measurements are essential 1, 5
• Do not overlook atypical presentations, particularly in women, elderly patients, and diabetics who may present with dyspnea or epigastric pain rather than chest pain 1, 2
• Do not misinterpret the T-wave inversion in aVL as benign when combined with ST elevation elsewhere 3, 5

Post-Intervention Monitoring

After successful reperfusion 1, 7:

• Monitor for ECG evolution: Resolution of ST elevation, appearance of Q waves, and development of T-wave inversions in leads with previous ST elevation 1, 7
• Deep symmetrical T-wave inversions (≥2 mm) in precordial leads after reperfusion may indicate severe proximal LAD stenosis with collateral circulation and require close follow-up 1, 3
• Serial ECGs to monitor for re-occlusion or extension of infarction 5
• Repeat echocardiography to assess final LVEF and wall motion 7