A man in his 40s with acute chest pain. What do you think?

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and GrauerA man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. He was eating lunch when he had sudden onset chest pressure, 9/10, radiating to his back, with sweating and numbness in both hands.Triage ECG:What do you think?It ' s a very " fun " ECG, with initial ectopic atrial tachycardia (negative P waves in inferior leads conducting 1:1 with the QRSs), followed by spontaneous resolution to sinus rhythm. In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteria in V4 and V5. In the limb leads, where we can see the ectopic atrial rhythm in this ECG, we see the classic situation of ectopic atrial P waves causing the illusion of inferior ST elevation which is more likely due to exaggeration of atrial repolarization ( " Ta waves " ). This situation has been named " Emery phenomenon. "In other words, the inferior " ST elevation " is due to the abnormal rhythm, and does not signify OMI or STEMI in any way. It is a known OMI mimic that we have shown on the blog many times.See these similar cases:A man in his 40s with epigastric pain and ST ElevationA man in his sixties with chest painWhy is there inferior ST elevation, and would you get posterior leads?Sudden CP and SOB with Inferior ST Elevation and in STE in V1. Is it inferior and RV OMI?Here is the Queen of Hearts interpretation of the ECG above:The patient had a bas...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs