What do you think of this ECG that was texted to me?

This ECG was texted to me by a colleague.  I assumed it was from a patient with symptoms compatible with ACS/OMI.What do you think?There is sinus rhythm with RBBB and ST Elevation in V2 which is concordant with the QRS.  The ST segment in RBBB should be ST depression, discordant to the positive R ' -wave (i.e., opposite direction of the upright R ' -wave).  But we sometimes see this concordant STE even in non-ischemic ECGs:PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don ' t miss case 4 at the bottom.This STE suggests OMI, but we have seen many cases like this that are false positives (OMI mimics).  I thought it didnot look like OMI but was not willing to risk the patient ' s life by saying so.I sent it to some EKG nerd friends (Pendell of course among them) and Pendell responded: " So difficult. I ’ll say real until proven otherwise.  Baseline could invalidate that in 10 seconds. "Of course he is right.  So I requested an old one.And, of course, pretest probability is crucial, so I asked for the history:A 60 year old presented with palpitations and chest tightness.In this case, if the patient needs PCI, he needs to be transferred because this hospital does not have a cath lab.So getting the right diagnosis here is crucial.I ran it by the Queen of Hearts PM Cardio app:And then I got the Queen ' s explainability:I relayed all our thoughts to my colleague.The first troponin returned at 113 ng/L (...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs