60-year-old man presents with right-sided hemiparesis and aphasia. What do you make of these EKG changes?
Sinus at 100/minute
Axis is normal
Intervals are normal
Ischemia/infarct – T wave inversion V1-4 with loss R waves (deep Q waves) in the same leads
T-wave inversion in the anterior leads has a broad differential. Deep, or giant, T-wave inversion has it’s own differential including CNS changes (see full differential under Impressive T-wave Inversion on TorreyEKG.com). More minor T-wave inversion can be seen with ischemia, acute PE, evolving or subacute STEMI, and many other causes.
These T-wave inversions in leads with well-formed Q waves suggest a subacute MI, possibly days to weeks old (the Q’s have formed, the ST-segments are back close to baseline, but the T-wave inversion can persist for weeks).
And what is the connection between a recent anterior MI and his presentation with a stroke? Once anticoagulated on heparin, a transesophageal ultrasound showed a large mural thrombus in a dyskinetic wall of his left ventricle.