50-year old with chest pain, “no ischemic changes”

Written by Jesse McLaren A previously healthy 50 year-old presented with 24 hours of intermittent exertional chest pain, radiating to the arms and associated with shortness of breath. It was ongoing on arrival in the emergency department. Below is the old ECG (on top) and then new ECG (on bottom). What do you think?There is normal sinus rhythm, normal conduction, normal axis, and tall precordial voltages with J waves from early repolarization. The old ECG has proportional ST elevation and T waves.But the new ECG has new Q waves in aVL and V2 (the distribution of the first diagonal artery) – and in the next context of Q waves, the T wave in V2 is upright and relative large. In a previously healthy patient with new and ongoing chest pain, this is concerning for acute occlusion of the first diagonal artery.Smith: Normal ST Elevation in V2-V4 never has an associated Q-wave!  So this STE cannot be considered normal even though there was STE on the previous ECG.But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. The emergency physician was called to see the patient 90 minutes later after the troponin I returned at 1100 ng/L. This confirms these Q waves are caused by an acute infarct. But is the artery still occluded?  The emergency physician noted the patient had improved but ongoing chest pain, and had the following repeat ECG:Ongoing large T wave in V2 with ongoing symptoms = still an o...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs