A man in his 60s with chest pain and LBBB

 Sent by Ali Khan MD, written by Pendell MeyersA man in his 60s with HTN, HLD, known prior LBBB, presented with episodes of chest pain radiating to the left shoulder, with diaphoresis and dyspnea. Episodes started yesterday after starting to exercise, came and went throughout the day, and he decided to present to the ED the next morning after the one of these episodes failed to resolve like the others.Here is his ECG at triage with ongoing pain (prior unavailable):Same image optimized by PM Cardio appWhat do you think?I sent this to Drs. Smith, McLaren, and Grauer all of whom immediately diagnosed LAD occlusion based on modified Sgarbossa criteria (any concordant STE, any concordant STD in V1-V3 for posterior OMI in LBBB, or any excessively discordant STE). There is also concerning morphology in V1-V4 with likely hyperacute T waves and STT convexity.Here are the STE/S measurements I make:V1:  3.0 / 13 mm = 23%V2: 4.5 / 15 = 30%V3: 4.5 / 21 = 21%V4: 3.0 / 9 = 33%In our validation study of the modified Sgarbossa criteria, we chose the cutoff of 25% for excessive discordance to maintain high specificity (spec 99%, sens 80%). Using 20% resulted in 84% sens and 94% spec, meaning it was still quite specific. When there are multiple contiguous leads with even greater than 15%, the specificity is anecdotally still quite high. Additionally, this does not take into consideration comparison of ratios from baseline, which can be very helpful.Back to the case:" Discussed case wi...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs