Chest pain and new regional/reciprocal ECG changes compared to previous ECGs: code STEMI?
Written by Jesse McLaren A 45 year old presented with two weeks of recurring
non-exertional chest pain, now constant for an hour. Below is old and then new
ECG (old on top; new below). What do you think?Both ECGs have normal sinus rhythm, normal conduction and
normal voltages. There ’s a change in axis that may interfere with direct
lead-to-lead comparison, but there appear to be larger T waves in I/aVL and new
TWI in III/aVF. But do they represent acute coronary occlusion? Because of the ECG changes in a patient with chest pain, and
with inferolateral hypokinesis on POCUS, the cath lab was activated. But
coronaries were normal, and serial high sensitivity troponin was undetectable. Formal
echo showed EF 55% with mild inferolateral hypokinesis without any prior for
comparison. Based on ECG changes and echo findings, the patient was diagnosed
as coronary vasospasm. Below is the discharge ECG, which showed the baseline
ECG without any reperfusion T wave inversion.The admission and discharge diagnosis both attributed the
ECG changes and echo findings to ischemia. But the echo findings could have
been old (especially with undetectable troponins), and the ECG changes could
have been non-ischemic. This brings up questions around hyperacute T waves and
reciprocal changes, dynamic ECG changes, and the ability to identify
preventable cath lab activations. OMI vs not OMI: what ’s
hyperacute and where’s the reciprocal change? Leads III/aVL are reciprocal ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Jesse McLaren Source Type: blogs
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