T for Three - Case 3 - Don't Bogart that ECG

Don’t Bogart that ECG my friend
Pass it over to me
Don’t Bogart that ECG my friend
Pass it over to me
You’ve been hanging on to it
And I sure would like a hit
— Based on the song “Don’t Bogart Me” (written in 1969 by Larry "Stash" Wagner, with lyrics by Elliot Ingber)

Introduction

These tracings are from a elderly man who presented with a acute myocardial infarct (AMI) in 1982. This was when I began to collecting interesting or puzzling or intriguing ECGs. This was also the era of "roll your own ECG" - the machine produced a continuous strip that was cut and hand mounted on a special page or mounting sheet (see Figure 2). The equipment was utilitarian, lacking the style and panache of other do it your self equipment like the "Badger" (Figure 1)

Figure 1 - The Badger Cigarette Case

The only information about this man is the date of his infarct and the four ECGs taken over 4 days. He had his infarct in the pre-thrombolytic era, and at the dawn of the pre-angioplasty era (the first successful coronary angioplasty treatment on an awake human was performed in 1977 by Andreas Roland Grüntzig).

The patient was probably treated with an intravenous infusion of lignocaine for the first 24hours after admission, and might have been anti-coagulated with heparin. He may have survived his heart attack, but will not be alive today. There is a certain melancholy in studying the tracings of these "dead souls" (See Comment 1)

ECG blogs are one way to share tracings that have been collected but not shared: they solve the "Don't Bogart that ECG" problem (See Comment 2). The ECGs are interesting because they show us the one of the possible ways that a (unmodified) ST elevation AMI can evolve. 

Day 1

Figure 2 - Initial ECG

The main findings in the initial ECG (Figure 2) are:

  • Sinus rhythm
  • Left anterior fascicular block (LAFB) causing left axis deviation
  • The T wave in Lead I is flat and the T wave in Lead aVL is inverted. There are small Q waves in Lead I and aVL, but these could be due to the LAFB
  • ST elevation in Leads V1 to V5, most marked in Leads V2 to V5. Leads V2 to V4 have tall T waves
  • There are tiny Q waves in Leads V2 to V4

These changes indicate an early ST segment elevation anterior AMI

 

Days 2-3 Subsequent ECGs

The frontal leads from an ECG taken on the second day, and two ECGs taken on the third day, are shown in Figure 3, and the the praecordial leads in Figure 4.

Figure 3 Frontal Leads

The main changes are:

  • The left axis deviation is slightly more marked
  • Inferior leads:
    • Leads II shows slight ST depression and T wave flattening 
    • Lead III has slight ST elevation and a flattened T wave
    • Lead aVF has a flattened T wave
  • Anterolateral leads (I and aVL) have inverted T waves
  • Lead aVR has 1 mm ST elevation

Day 3A: The changes are similar to those on Day 2, although the slight ST elevation in Lead aVR has resolved

Day 3B: There is ST depression and marked T wave inversion in Leads I and aVL, and ST depression and T inversion in Leads II and aVF. The ST segment in Lead aVR is elevated.

Figure 4 - Praecordial Leads

There are deep Q waves in Leads V1 to V3 , with loss of R waves and concave ST segment elevation in Leads V2 and V3. The amplitude of the R waves in Leads V4 and V5 is less than in the initial ECG. These changes are due to the progression of the AMI.

Day 3A and 3B: The major change is the progressive development of giant T wave inversion (amplitude of the inversion is greater than 10 mm) in Leads V2 to V6. The QT interval in the last ECG (Day 3B)  is prolonged at 680 msec.

Summary of ECG changes:

ST elevation AMI with major changes seen over 3 days in Leads V2 toV5:

  • Initial ST elevation and tall T waves
  • Loss of R waves and development of Q waves 
  • Giant T wave inversion 
  • Prolonged QT interval

The causes of giant T wave inversion have been listed in a previous post (Case 1 - Vladimir)

 

Comments

Comment 1.

Dead Souls is a novel published in 1842 by the Russian novelist Nikolai Gogol. In post-Napoleonic Russia landowners owned serfs who worked the land. A man's wealth was not only determined by the amount of land he had, but also by the number of souls he owned. Tchitchikov, the main character of the story, decides to purchase dead souls in order to become rich.

Comment 2. In June 1968 ABC Records in America released the first album by The Fraternity of Man, a California-based rock band whose members included former Mothers of Invention guitarist Elliot Ingber and a 17-year-old singer and songwriter named Larry "Stash" Wagner.

The album included a country flavoured song titled "Don’t Bogart Me." The song’s lyrics were written by Wagner, and the music was written by Ingber. The song featured in the counterculture classic Easy Rider, released in 1969. The phrase "Don’t Bogart That Joint" - from the opening line of the song - became a slang term meaning "don’t keep holding onto that marijuana joint - pass it on and let other people have some."

The use of "Bogart" as a verb eventually became an idiom used in association with things other than just a marijuana joint e.g.  "Don't Bogart that drink" or "Don't Bogart that ECG"

There are various theories about why Humphrey Bogart’s last name became a verb that was originally tied to smoking. A plausible explanation is that, in many of his films, Bogart often has a lit cigarette hanging from his lips but is not actively smoking it. He’s just letting it burn and turn to ashes.

"Don't Bogart That Joint My Friend..."