A woman in her 50s with chest pain and dyspnea

Submitted by anonymous, written by Pendell MeyersA woman in her 50s presented to the Emergency Department with chest pain and shortness of breath that woke her from sleep, with diaphoresis. She had a prior history of " NSTEMI " one month ago, during which she had a coronary angiogram reportedly showing no stenosis in any coronary artery. Her vitals were within normal limits.Here is her triage ECG:PM Cardio Version (see original screenshot I received below)Original image. What do you think?Here is the prior ECG on file (from 1 month ago, when she was having " NSTEMI " with high sensitivity troponin peaking at 200 ng/L):What do you think now that you can see the prior ECG?These two ECGs were sent to me, with the clinical info above. I replied: " Can you go place the leads yourself and make sure they are normal, then repeat the EKG? DDx, is pulse tapping artifact, reperfusion, and takotsubo. Pulse tapping artifact usually goes away with fixing electrode placement problem, and lead I looks so normal that this is probably pulse tapping artifact. "I sent the first ECG with no information at all, and without the old ECG, to Steve Smith who immediately just texted back: " pulse tapping. "Smith: how did I know this instantly?  Because lead I is normal.  All other leads are very weird.  In pulse tapping artifact, one of lead I, II, and III will be normal.Another ECG was performed immediately with new electrodes and correct placement (no information given about wheth...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs