An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain

This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System.The patient presented to an outside hospitalAn 80yo female per triage “patient presents with chest pain, also hurts to breathe”PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB.HPI: Abrupt onset of substernal chest pain associated with nausea/vomiting 30 min PTA.  She reports associated SOB but no dizziness or LOC.  She was given NTG at home before coming to the hospital. This was the ECG obtained at triage.This ECG was recorded and was reviewed remotely by a cardiologist:What do you think?Deep saw this later and thought this was clear inferior-posterior-lateral OMI.He sent it to me with no other information and I wrote back " 100% diagnostic of LBBB with inferior-posterior-lateral OMI "---There is atrial paced rhythm with Left Bundle Branch Block (LBBB).  1. There are hyperacute T-waves in inferior leads, with depressed ST takeoff (inferior de Winters -- yes, de Winter ' s can manifest in any territory and, yes, it can manifest in the presence of LBBB.)2. There is concordant ST depression in V3.  It only takes one such lead to fulfill the 2nd criterion of theSmith Modified Sgarbossa criteria.3. There are hyperacute T-waves in V5 and V6.The Queen of Hearts agrees:Here the Queen explains why:However, it was not interpreted correctly by the providers:ED interpretation of ECG: " paced rhythm, LBBB bu...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs