A woman in her 50s with acute chest pain

Submitted and written by Anonymous, edits by Meyers and SmithA 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache.Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 FTriage ECG:ECG Interpretation:Sinus rhythm with normal QRS. There is slight STE in V1, V2, and aVR, with STD in V3-V6, I, aVL, and II. There are T waves in lead III which are suspicious for hyperacute T waves, with reciprocal negative large T wave inversions in aVL. I do not think this ECG is by itself diagnosticof OMI (full thickness, subepicardial ischemia), but comparison to a previous might reveal this ECG as diagnostic of OMI.Smith comment:However, with the STD in I, II, and V4-6, it is diagnostic of ischemia [the question is whether that ischemia is due to 100% occlusion [OMI, with subepicaridal (full thickness) ischemia], or whether it is incomplete ischemia [subendocardial only].Here is her prior ECG (4 months prior) on file:Now, with comparison to prior ECG, the findings are new and concerning for inferior OMI, subendocardial ischemia, or both (which is essentially Aslanger ' s pattern).  Smith comment: There is a change in V2 as well, with less normal STE and a smaller T-wave with some inversion.  This is likely to be due to high lead placement (as evidenced by a negative P-wave -- should always be upright in V2).  Nevertheless, this sug...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs