A man in his 70s with chest pain

 Case submitted by Rachel Plate MD, written by Pendell MeyersA man in his 70s presented with chest pain which had started acutely at rest and has lasted for 2 hours. The pain was still ongoing at arrival. He also noted a bilateral " odd feeling " in his arms. He stated it was similar to prior heart attacks. He had history of prior MIs and CABG, as well as diabetes, hypertension, and hyperlipidemia.  Here is his triage ECG:PM Cardio version:With no other information at all, I sent this ECG to Dr. Smith, who replied: " I think it is real. V3. STD in V4-5 too. "What he means is: he thinks the signs of inferior and posterior OMI are real. While the inferior findings have morphology that do not make it 100% specific (but still very concerning, especially later when the baseline is available for comparison), the combination with unexplained STD in V3-V4 (posterior OMI) makes the inferior OMI more certain as well.In other words, this ECG shows sinus rhythm, normal QRS complex, and:--Inferior OMI: STE in III, hyperacute T waves in lead III, reciprocal STD and TWI in aVL.--Posterior OMI: unexplained STD max in V3-V4.Prior ECG on file (probably " baseline " ):Importantly, leads III, aVL, and V3-V4 are normal at baseline, making the new findings above more certain evidence of OMI.His initial troponin T was 15 ng/L (only two hours since pain onset).About an hour later, he was then found on the floor in cardiac arrest in the ED. He underwent CPR and then was shocked ou...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs