Chest pain and anterior ST depression. What ’s the cause(s)?

Written by Jesse McLaren, with edits from Smith and GrauerA 60 year old with no past medical history presented with two hours of chest pain radiating to the left arm, with normal vitals. What do you think?  I sent this to Dr. Meyers without any other information, and he responded, “do you have a prior to make sure that it is all just because of the delta wave? Would be careful to make sure it’s not inferoposterior OMI superimposed on baseline WPW.” In other words, when there are ST/T wave changes thefirst question is whether there ’s abnormal depolarization, because this will be followed by abnormal repolarization. Here there is WPW with pre-excitation (short PR and delta wave that widens the QRS). In this case there are tall R wavesin precordial leads (from a left sided accessory pathway), which are followed by discordant ST depression and T wave inversion. But thesecond question is whether or not there is superimposed signs of Occlusion MI. WPW causes appropriately discordant ST/T wave changes, so superimposed OMI can be identified byinappropriately concordant orexcessively discordant ST/T changes. Here, there could be subtle inferior concordant ST elevation from inferior OMI, and theprecordial ST depression couldbe exaggerated by superimposed posterior OMI. There were no prior ECGs, the first ECG was signed off as unremarkable, and the patient waited to be seen. An hour later the first troponin returned at 49 ng/L (normal<...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs