A man with chest pain off and on for two days, and " No STEMI " at triage.

 Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen SmithA 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.What do you think?This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 mm STE in III, and possibly 0.5 mm in aVF), but there is clear evidence of OMI findings on this ECG. Leads II, III, and aVF have hyperacute T waves with reciprocal T wave inversions and down-sloping STD in I and aVL; along with ST depressions in the precordial leads that is maximal in V2-V4, this isdiagnostic for inferior and posterior OMI.Meyers note: The slightly complicating feature of this ECG is that the QRS likely represents LVH, with high positive voltage in I and aVL, and relatively high negative voltage in inferior leads. Some may have thought that these ST segment shifts were attributable to the LVH, but these shifts are out of proportion to the trained eye. As far as I am aware, we do not yet have great studies of the quantified " appropriate discordance " of LVH. We have tried to study it before, only to find that we cannot obtain enough cases of OMI with simultaneous high voltage in the leads with OMI findings, to study it. Armstrong et al. studied this with insufficien...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs