OMI can be very subtle and easy to miss, but be a very large infarction.

I was reading ECGs on the system and came across this one.  There is minimal STE in II, III, with an inverted T-wave in aVL.There is a very flat ST segment in V2, with 0.5 mm of STD, highly suspicious for posterior OMI.We showedin this paper that ANY amount of STD maximal in V1-V4 (especially in V2) in a patient with chest symptoms is posterior OMI until proven otherwiseI knew that if this is a patient with chest discomfort, that it is an infero-posterior OMI.So I went to the chart and found that it was from a 50-something woman with CP of a couple hours duration.Unfortunately, the OMI was not seen.When the first troponin returned slightly elevated, this ECG was recorded 100 minutes later (too long to wait for a repeat ECG!!):Now it is not subtle: there is clear, obvious inferior posterior OMI.At this point, the cath lab was activated.  Angiography showed:100% Distal RCA occlusion. Pre-procedure TIMI 0 flow was noted. Stent placed.  Post Procedure TIMI III flow was present. ECG recorded after PCI:Large upright T-waves in V2, V3 indicated posterior reperfusion.Later after PCI:Trop went over 50,000 ng/L very quicklyEcho:The estimated left ventricular ejection fraction is 58 %.Regional wall motion abnormalitybasal-inferior (this is the posterior wall), akinetic.Regional wall motion abnormality basal inferoseptum, akinetic.Learning Points:1. Acute 100% coronary occlusion can be VERY subtle on the ECG.2.Record serial ECGs every 15 minut...

Source: Dr. Smith's ECG Blog - January 15, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs