Avoid common mistakes on your manuscript.
Answer
The triangular QRS-ST‑T waveform (TW) pattern, also called ‘tombstone’ or ‘graveyard’ and more recently ‘shark fin’ pattern, is a rare electrocardiography pattern that is associated with a poor prognosis in patients with ST-segment elevation myocardial infarction [1,2,3]. The ECG (Fig. 1 in the question) showed supraventricular tachycardia and an anterior TW pattern. Echocardiography at hospital admission revealed changes in segmentary motility of the left ventricle corresponding with descending artery territory, and the left ventricular systolic function was severely reduced. No evidence of mechanical complications was found. The patient was referred to urgent coronary angiography, which revealed occlusion of the ostial left anterior descending artery (Fig. 2). After multiple unsuccessful attempts to cross the thrombotic lesion with the guidewire, the patient had another cardiopulmonary arrest. ‘Life-saving’ intracoronary fibrinolysis with alteplase during resuscitation manoeuvres was attempted, without success.
A TW pattern is an unusual finding as these patients usually die rapidly, before being able to get medical assistance and before an ECG is recorded. It is of the utmost importance that medical personnel recognise this pattern immediately, because this allows for an urgent response, including early reperfusion.
References
Cipriani A, D’Amico G, Brunello G, et al. The electrocardiographic “triangular QRS-ST‑T waveform” pattern in patients with ST-segment elevation myocardial infarction: Incidence, pathophysiology and clinical implications. J Electrocardiol. 2018;51:8–14.
Smith SW. Dr. Smith’s ECG Blog. Minneapolis. 2016. http://hqmeded-ecg.blogspot.com. Accessed 26 Mar 2016.
Tarantino N, Santoro F, Brunetti ND. Triangular “shark fin-like” ST modification in takotsubo syndrome: challenging the concept of ST-elevation patterns without coronary occlusion? J Electrocardiol. 2018;51:1157–8.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
V. Devesa Neto, J.M. Santos, J.G. Pereira, L.F. Santos and B. Marmelo declare that they have no competing interests.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Devesa Neto, V., Santos, J.M., Pereira, J.G. et al. A ‘fishy’ ECG in a patient with chest pain. Neth Heart J 30, 119–120 (2022). https://doi.org/10.1007/s12471-021-01632-0
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12471-021-01632-0