Tombstoning Pattern on Electrocardiogram: A Marker of Extensive Myocardial Infarction – Case Report and Clinical Insights

Abstract

The “tombstoning” ST-segment elevation pattern on an electrocardiogram (ECG) is an ominous sign of a large and potentially fatal anterior wall myocardial infarction (MI). It indicates massive transmural ischemia with poor myocardial reserve and high risk of complications. This article presents a case of a 54-year-old male with acute chest pain whose ECG showed a tombstone pattern in precordial leads, followed by a discussion of the pathophysiology, prognostic implications, and clinical management associated with this ECG finding.

Introduction

Myocardial infarction remains a leading cause of morbidity and mortality worldwide. Rapid recognition and intervention are critical to improving outcomes. Among the various ECG patterns, the “tombstoning” appearance of ST-segment elevation is associated with more extensive infarction, poor left ventricular function, and higher mortality. This pattern is characterized by massive ST elevation where the upward convexity of the ST segment merges with the T wave, resembling a tombstone.

Case Presentation

Patient: Mr. D.S., a 54-year-old male
Occupation: Auto mechanic
History: Presented to the Emergency Department with crushing retrosternal chest pain of 2-hour duration radiating to the left arm and jaw.
Risk Factors:

  • Smoker (30 pack-years)
  • Hypertensive
  • No known diabetes
  • No prior cardiac history

On Examination:

  • Pulse: 102/min, regular
  • BP: 88/60 mmHg
  • RR: 20/min
  • JVP: Raised
  • Cold extremities, diaphoresis present
  • S1, S2 normal; no murmurs
  • Basal rales bilaterally

ECG Findings:

  • ST-segment elevation of >5 mm in leads V2–V5
  • Convex upward ST elevation blending into tall T waves
  • Absence of distinct J point
  • Poor R wave progression
  • Q waves in V1–V3
  • Reciprocal ST depression in leads II, III, and aVF

Diagnosis: Acute anterior wall ST-elevation myocardial infarction (STEMI) with tombstone pattern

Management:

  • Immediate dual antiplatelet therapy (aspirin + ticagrelor)
  • Intravenous nitrates and morphine
  • Oxygen supplementation
  • Emergency coronary angiography revealed total occlusion of proximal LAD
  • Primary percutaneous coronary intervention (PCI) with stenting performed

Outcome:

  • Successful revascularization
  • LVEF post-PCI: 35%
  • Discharged on Day 5 with optimal medical therapy

Discussion

What is the Tombstoning Pattern?

The term “tombstoning” refers to a distinctive ST elevation configuration seen in acute MI:

  • ST elevation is tall, convex upwards, and merges with the ascending limb of the T wave
  • QRS complex is shortened or absent, and the ST segment directly follows the R wave
  • R wave may be diminished or absent
  • T wave appears large and upright, forming a silhouette reminiscent of a tombstone

Common Leads Involved: V2 to V5 (anterior precordial leads)
Most Common Cause: Proximal left anterior descending (LAD) artery occlusion

Pathophysiology

Tombstoning reflects:

  • Massive transmural ischemia: affecting full-thickness myocardium due to abrupt coronary occlusion
  • Loss of depolarization reserve: early QRS-ST-T merging indicates failure of repolarization gradients
  • High electrical instability: patients prone to malignant arrhythmias and cardiogenic shock
  • Left ventricular dysfunction: due to large infarct territory, leading to heart failure or sudden death

Prognostic Implications

Tombstoning is associated with:

  • Increased infarct size
  • Reduced left ventricular ejection fraction
  • Higher in-hospital and 30-day mortality
  • Increased incidence of complications:
    • Cardiogenic shock
    • Ventricular fibrillation
    • Free wall rupture
    • Left ventricular aneurysm

In a study by de Winter et al., tombstone morphology was present in 15% of anterior STEMIs and had a 30-day mortality rate over 20%.

Differential Diagnoses

Although tombstoning is typical of extensive MI, other mimics include:

  • Early repolarization syndrome: typically in young males, lacks symptoms, and has notched J points
  • Pericarditis: diffuse ST elevation, PR depression, no reciprocal changes
  • Hyperkalemia: tall T waves, but without typical QRS-ST morphology
  • Left ventricular aneurysm: persistent ST elevation weeks after MI

Management Approach

Immediate Goals:

  1. Reperfusion therapy – PCI or thrombolysis
  2. Hemodynamic stabilization
  3. Arrhythmia prevention and management

Long-term Goals:

  • Optimal secondary prevention: statins, beta-blockers, ACE inhibitors, antiplatelets
  • Cardiac rehabilitation
  • Risk factor modification: smoking cessation, BP control, lifestyle changes

Conclusion

The tombstoning pattern on ECG is more than just a dramatic visual—it signifies a life-threatening, large-area myocardial infarction, often involving the proximal LAD. Prompt identification and urgent revascularization are vital to improve survival. Clinicians should remain vigilant for this pattern and act swiftly, as every minute of delay worsens the prognosis.

References

  1. de Winter RJ, et al. “ST Elevation Morphology in Acute Myocardial Infarction.” Heart. 2004.
  2. Birnbaum Y, et al. “The ECG in Acute STEMI: Correlation with Angiography and Clinical Outcomes.” Am Heart J.
  3. Thygesen K, et al. “Fourth Universal Definition of Myocardial Infarction.” Circulation. 2018.
  4. Amsterdam EA, et al. “2014 AHA/ACC Guidelines for Non–ST-Elevation ACS.” JACC.
  5. Antman EM, et al. “Management of Patients with STEMI.” NEJM.
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