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: Source Type: blogs