70-year-old with acute chest pain, STEMI negative: just an old infarct?

Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chest pain radiating to the neck, associated with shortness of breath. What do you think?There ’s normal sinus rhythm, first-degree AV block, normal axis and voltages. R wave progression is abnormal: there are Q waves in aVL/V2-3 and loss of R wave in V2. This is accompanied by minimal ST elevation in aVL/V1-V2 and more pronounced inferior reciprocal ST depression, and minimal ST depression V5-6. This is diagnostic of OMI, either proximal LAD or first diagonal. Q wave, old infarct?Below is the old ECG, showing that all these changes are new – including the Q waves.While the final interpretation on the new EGC is “anteroseptal infarct, old”, the patient had developed acute Q waves after only 2 hours of ischemic symptoms. Acute Q waves are a marker of severe ischemia and a predictor for delayed reperfusion. This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for anacute coronary occlusion. As he documented,“This patient is experiencing chest pain consistent with an acute coronary syndrome. I am concerned about these ECG findings as they may represent a subtle occlusion.” So he asked for a stat cardiology consult to consider cath lab activation.OMI or STEMI...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs