A 40-something with 2 hours of new active chest pain and new T-wave inversion

A 41-year-old male who presents to the emergency department with chest pain. Patient reports approximately 2 hours prior to arrival he developed a sharp chest pain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling.  No shortness of breath. No recent travel. No cough. No cardiac history. Here is his ECG:He had a previous ECG on file, from many years prior:What do you think?There is new T-wave inversion in inferior leads and V3-V6.  This is recorded during pain.  The faculty physician thought this is highlylikely to be ACS.  However, most T-wave inversion during pain is nonspecific.  T-wave inversion AFTER resolution of anginal type pain is highly likely to be due to reperfusion.On occasion, unstable angina can present with reversible T-wave inversion during pain.  When the ischemia is resolved, if there is no infarction, the T-wave can normalize.  This is in contrast to Wellens ' syndrome, which involves at least a small amount of infarction (troponin elevation) and in which the T-wave inversion evolves into deeper and deeper T-wave inversion.See these 2 contrasting cases:Classic Evolution of Wellens ' T-waves over 26 hoursDynamic, Reversible, Ischemic T-wave inversion mimics Wellens ' . All trops negative.This case directly above was not in the era of high sensitivity troponin. Unstable angina in the era of hs trop still exists.  I have never see...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs