Acute dyspnea in an older woman, is it OMI?

 Written by Willy FrickA woman in her 90s with a history of end stage renal disease and complete heart block status post dual chamber pacemaker presented from home with acute onset dyspnea. ECG is shown below.What do you think?The ST and T wave abnormalities jump off the page, but let ' s set that aside just for a moment to review the tracing systematically. The rate is 60 (and remember, slower heart rates are often seen in OMI). Close inspection revealsventricular pacing spikes, best seen in aVL. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it is still critical to determine the atrial rhythm. In this case, it isatrial fibrillation. This could be easily overlooked since there is complete heart block, but recognizing the atrial arrhythmia may mean prescribing anticoagulation to prevent stroke.See this case: Computer often fails to diagnose atrial fibrillation in ventricular paced rhythm, and that can be catastrophicGiven that this is a ventricular paced rhythm, we judge the presence or absence of OMI using Smith Modified Sgarbossa Criteria. It is hard to identify exactly how deep the S waves in I and aVL are, but there could be disproportionate ST elevation and hyperacute T waves with reciprocal changes in III and aVF, altogether concerning for high lateral OMI.The ER immediately contacted cardiology for consideration of emergent catheterization. Cardiology felt that there was b...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs