A woman in her 70s with chest pain

 Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, SmithA woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. She felt nauseous and lightheaded with no neurologic deficits. EMS noted prehospital vitals for heart rates in the 60s, SPO2 of 98% on room air, initially hypotensive to 66/34 with improvement to 100/70 after 800 mL of IV fluids by EMS.  Here is her ECG on arrival to the ED: What is your differential? What are your next steps?The ECG is quickly reviewed and shows sinus rhythm with normal QRS complexes. There is ST depression in leads V3-V6, I, aVL, II, III, and aVF, with ST elevation in aVR. Importantly, there is also STE in aVL, as well as V1. The differential is:Posterolateral OMI or subendocardial ischemiaThe distinction between posterior OMI and subendocardial ischemia can be important and sometimes difficult. Usually, ST depression proportionally maximal in V1-V4 indicates posterior OMI, whereas ST depression maximal in V5-V6 (with similar STD in II and reciprocal STE in aVR) indicates subendocardial ischemia. In posterior OMI, the STD in V4 improves significantly or resolves completely from V4 to V6; whereas, in subendocardial ischemia, the STD persists in severity or worsens from V4 to V6.STD/R wave ratios:V3: 2.5 / 16.5 = 15%V4: 2.0 / 11.0 = 18%V5: 0.5 / 5 = 10%, or perhaps it is closer to 0.75 / 5 = 15%V6: 0.5...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs