A man in his 50s with acute chest pain without STEMI criteria. Trop negative. Cath lab cancelled. But how about the ECG and echo?

Case submitted by Matt Tanzi MD, written by Pendell MeyersA man in his early 50s presented with substernal chest pain and that started 1 hour prior to arrival. There was some radiation to the left jaw and diaphoresis. He had ongoing pain on arrival.Initial triage ECG:What do you think?I sent this to Dr. Smith who immediately replied that it is diagnostic of OMI, but difficult to tell whether it is1) anterolateral with de Winter morphology, or instead2) A combination of Aslanger ' s pattern (inferior OMI with single lead STE in III and reciprocal STD in I, aVL, plus widespread STD of subendocardial ischemia) with posterior(V2 STD) and RV extension(V1 STE). In other words, does V2 indicate ST depression of posterior OMI? or is the ST depression and hyperacute T wave indicative of de Winter hyperacute OMI morphology of the anterior wall? It is difficult to tell, but either way: OMI needing reperfusion.The ECG shows sinus tachycardia, grossly normal QRS complex, ST depression from V2-V6, and in I and aVL. There are possibly hyperacute T waves in V2 (maybe also V3 and V4), constituting de Winter morphology (hyperacute T wave taking off from depressed ST segment). V1 has a tiny amount of STE and a hyperacute T wave also. The ECG overall is diagnostic of OMI.The cath lab was activated. He received aspirin and heparin bolus. The cardiologist immediately evaluated the patient and stated that the ECG did not meet STEMI criteria, so the cath lab was cancelled. T...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs