A young patient with diminishing pain with a subtle but diagnostic ECG.

Written by Emre Aslanger(Emre is our newest editor.  He is an interventionalist in Turkey and one of 3 originators of the OMI/NOMI paradigm, along with Pendell and Smith. Here are his publications.)CaseA 39-year-old male without prior medical history presents with chest pain that started 2 hours prior to presentation. He says that the pain intensity was 10/10 at home but now about 4/10. His medical exam is unremarkable. He has no cardiovascular risk factors except smoking for 10 pack-years. He denies any illicit drug use. His ECG is shown below. What do you think ?Although not striking, this is clearly a diagnostic ECG for infero " posterior " myocardial infarction due to coronary occlusion (OMI), most likely due to left circumflex (LCx) artery occlusion. There is clear ST-segment depression in V2-5, which peaks around V4. The morphology in V2 is especially concerning for a reciprocal change to " posterior " ST-segment elevation (STE). There is also subtle STE in inferior leads,with hyperacute T-waves and accompanying Q waves in lead II and aVF. Lead III has a fractioned QRS complex. These all are highly unlikely to be seen in a 39-year-old man without previous cardiac history.  Emergency physician doubts the diagnosis and wants to see another ECG with posterior leads. It is given below. The patient is highly stable and says his pain is now around 2/10. What would you do ?Leads V4-6 here are actually V7-9. It is a good custom to write it on the paper ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs