"Giant R wave" electrocardiogram pattern during exercise treadmill test: A case report

Abstract

IntroductionThe exercise treadmill test is widely used in the evaluation of patients with suspected or known coronary artery disease. The typical ischemic response used to be ST-segment depression.Case presentationWe describe a case of a 51-year-old Caucasian man with an unusual ischemic response during the exercise treadmill test: a "giant R wave" electrocardiogram pattern as a manifestation of hyperacute ischemia that resolved with sublingual nitroglycerin. Coronary catheterization showed a severe stenosis in a proximal dominant circumflex coronary artery. We hypothesize that, in this case, the "giant R wave" pattern was related to severe hyperacute ischemia due to coronary spasm superimposed on the atherosclerotic lesion, which probably caused complete occlusion of the artery. The patient was successfully treated with coronary percutaneous revascularization.ConclusionsThis is a dramatic and rare ischemic response during the exercise treadmill test, in which, a rapid administration of nitroglycerin can prevent life-threatening events.

Prinzmetal Angina in a Young Patient with Essential Thrombocythemia, After Anagrelide Initiation - Case Report and Literature Review

“…Electrocardiographic leads with ST-segment elevation have a good prediction value for the site of hypoperfusion and the same observation was valid in our case (31). The particular ECG aspect of giant R and monophasic QRS-ST complex may be rarely observed, except from variant angina, in acute myocardial infarction and after percutaneous transluminal coronary angioplasty (32).…”

Ominous Electrocardiographic Patterns in an Older Adult With Chest Pain

“…3 Giant R-wave syndrome is uncommon and observed primarily in the hyperacute phase of myocardial infarction, variant angina, and after percutaneous transluminal coronary angioplasty or experimental coronary artery ligation. 4 Giant R-wave syndrome reflects the presence of a large area of transmural myocardial ischemia and predicts ventricular fibrillation, accounting for high in-hospital mortality. Aizawa and colleagues 5 reported that this ECG pattern was significantly more prevalent among the selected population with STEMI complicated by ventricular tachycardia (48.0%) compared with the control population of uncomplicated STEMI (4.1%).…”

“…In the literature, it has also been described as a “lambda-like” pattern (J waves accompanied by ST-segment elevation) . Giant R-wave syndrome is uncommon and observed primarily in the hyperacute phase of myocardial infarction, variant angina, and after percutaneous transluminal coronary angioplasty or experimental coronary artery ligation . Giant R-wave syndrome reflects the presence of a large area of transmural myocardial ischemia and predicts ventricular fibrillation, accounting for high in-hospital mortality.…”

Transient Giant R Wave as a Marker for Ischemia in Unstable Angina

“…The “giant R wave” of acute myocardial ischemia has previously been reported in patients with acute myocardial infarction [ 3 - 5 ], in variant (Prinzmetal) angina [ 6 ], during exercise treadmill stress test [ 7 - 8 ], in the setting of percutaneous transluminal coronary angioplasty [ 9 ], and following coronary artery ligation in dogs [ 2 ]. Giant R waves, to our knowledge, have not yet been reported in the setting of unstable angina.…”