Why is the angiogram normal?

Written byWilly FrickA man in his 50s with a 15 pack-year smoking history presented to his primary care physician ' s office complaining of intermittent headache. He also complained of intermittent mild chest pain radiating into into both shoulders and his back, as well as occasional unexplained sweating. (Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually modestly more predictive). The primary care physician ' s note indicates low suspicion for cardiac ischemia, but " for completion, check troponin and ECG. " If an ECG was obtained in the office, it was not saved. The patient had his blood drawn that morning, and troponin I was 6.496 ng/mL (ref.< 0.033). The PCP ' s office called the patient and advised him to present to the ER immediately. His ECG is shown.ECG 1Readers of this blog will have no trouble recognizing this as an OMI with some early reperfusion. Looking through the ECG in detail, we see:STE and HATW in II, III, aVF with terminal reperfusion TWISTD in aVL with overly upright T waves, reciprocal to inferior reperfusionST flattening with subtle depression in V1 and probably V2, plus overly upright T waves suggestive of reperfused posterior occlusionSubtle coved STE in V6 with terminal TWI (and to a lesser extent V5) consistent with reperfused lateral occlusionHe underwent emergent angiography, which showed normal coronary arteries. His troponin peaked at 10.310 ng/mL and trend...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs