A woman in her 50s with chest pain and lightheadedness and " anterior subendocardial ischemia "

 Written by Pendell MeyersA woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. Here is her triage ECG during active symptoms:What do you think?The ED physician read this as " Normal sinus rhythm. LVH. Marked ST abnormality, possible anterior subendocardial injury. "  Smith: I suspect this was a confirmation of the conventional computer interpretation.  These are often wrong and lead the physician astray.This is wrong on many levels. The rhythm is some form of heart block (see Ken ' s comments at end of post) with junctional escape. The STD maximal in V1-V4 is diagnostic of acute transmural posterior wall ischemia, most likely due to posterior OMI. Subendocardial ischemia does not localize, and subendocardial ischemia presents with STD maximal in V5-6, II, and STE in aVR.Here is the Queen of Hearts AI interpretation:I ' m really surprised the confidence isn ' t higher, I ' ve seen QOH be more confident on more difficult ones that this. Anyway, she does say OMI.So the patient ' s OMI was initially missed. It does not meet STEMI criteria. Luckily, 45 minutes later, with ongoing pain and a troponin I that resulted at 136 ng/L, the ECG was repeated:What do you think now?Easy for anyone.Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach).Finally the OMI was realized.She was taken to cath and found to have total mid RCA occlusion, TIMI ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs