Chest pain, peak troponin 100,000 ng/L and this ECG on discharge: what ’s the diagnosis?

Written by Jesse McLaren, with edits by Smith Usually cases are presented in chronological order the way they appear in real life. But this case will be represented in reverse chronological order. At each step we ’ll ask the question, “what’s the diagnosis?” using the STEMI paradigm (was this STEMI or NSTEMI?) and OMI paradigm (was this Occlusion MI or Non-Occlusion MI?).  Discharge A 60 year old without prior cardiac history was admitted with chest pain, had a peak troponin of 100,000 ng/L (normal<16 in female and<26 in males), and was discharged with the following ECG (#4). What ’s the diagnosis?   There ’s normal sinus rhythm, normal conduction, normal axis and normal voltages. There’s loss of R waves V2-3 and reperfusion T wave inversion prominently in V2-4 and more subtle in I/aVL/V5, indicating proximal LAD reperfusion after anterior infarct (i.e. not Wellens). Was this STEMI or NSTEMI? We can ’t say, because we don’t know if there was ST elevation on the ECG before angiography. So regardless of the angiographic findings, peak troponin, or evidence of reperfusion,the STEMI paradigm can ’t answer, even in hindsight, the basic question “what’s the diagnosis” without the ECG that preceded the angiogram. But with the OMI paradigm, we can diagnose an LAD occlusion that led to loss of R waves (with massive peak troponin) before reperfusion.  Angiogram  Let ’s go back in time to the a...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs