A man in his 40s with 3 days of stuttering chest pain

Written byWilly FrickA man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chest pain. It started while he was at rest after finishing a workout. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It woke him the next day and radiated into his back. He was only able to sleep while sitting in a chair. He went to urgent care and had an ECG (not available) which was interpreted as normal, and was sent home. His pain returned, and he went back to the urgent care but was sent to the ER. His ECG is shown:What do you think?Here is the Queen ' s verdict and translator:For me, it is hard to make much of this ECG. The most troublesome lead is aVL which shows abnormal ST flattening and perhaps even a very tiny of depression. With no context, I would call it sinus rhythm with non-specific ST&T wave abnormalities.Smith: there is a bit of STE in inferior leads, and aVL has not only some STD, but it is downsloping, which is very worrisome for inferior OMI.High sensitivity troponin I (hsTnI) obtained around that time was 5548 ng/L (ref.< 35). This is enough to cause serious alarm. Distilling this case into its most salient components, a man with multiple risk factors for coronary disease is presenting with several days of chest pain and markedly elevated troponin with no other reason to explain the lab abnormality (e.g. sepsis). It is impossible to overstate the impo...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs