A 55-year-old female patient presented with breathlessness and was found to have signs of acromegaly such as enlarged hands and feet from a previous pituitary tumor surgery. Her ECG showed signs of left ventricular hypertrophy but was otherwise normal. The next day, she experienced chest pain and went into cardiogenic shock. Resuscitation efforts were unsuccessful and she suffered cardiac arrest. Her ECG then revealed subtle signs of myocardial ischemia that were discussed, including tall, broad T waves and ST depression in lead aVL.

1. SUBTLE SIGNS OF MYOCARDIAL
ISCHAEMIA ON ECG
Dr Ingole, MD Internal Medicine
Pune

2. • 55 yr old Female Patient admitted with
breathlessness on exertion
• Past History : Operated for Pituitary tumor 2 yrs ago
• Personal History : Unmarried, Menopausal

3. On Examination
• Afebrile
• Pulse 84/min, Regular
• BP 140/90 mmHg
• Built Stout
• Broad Big Supra Orbital Ridges
• Big Nose
• Macroglossia
• Big Spade like Hands, Wide and Big feet

4. Systemic Examination
• RS : NAD
• CVS : NAD

5. Clinical Impression
• Acromegaly with Operated Pituitary adenoma to r/o
underlying cardiac disease- CAD vs
cardiomyopathy secondary to acromegaly

6. Investigations
• All routine Investigations Normal
• ECG : NSR, LVH

7. Next day …
• Patient had sudden onset, typical chest pain with
hypotension in the morning.
• Impression : Acute Coronary Event with Cardiogenic
Shock
• Resuscitation was initiated in the ward
• Patient had cardiac arrest and unfortunately could not
be revived.

8. ECG was done …

9. SUBTLE SIGNS OF MYOCARDIAL
ISCHAEMIA ON ECG
• Tall, broad T waves
• NTT wave in V1
• Wellen’s T waves
• De Winter’s ST-T abnormality
• Isolated ST depression in aVL
• Inverted fish hook sign
• aVR and V1…..discussed previously by Dr Karekar

10. Himalayan T Wave

11. Hyperkalemia

12. Wellen’s T wave

13. De Winter’s T Wave

14. Inverted Fish Hook sign

15. Isolated aVL T inversion

16. LMCA

17. Thanks