56 year old male had 5/10 chest pain for several hours, then presented to the ED in the middle of the night with 1/10 pain.

A 56 year old male with PMHx significant for hypertension had chest pain for several hours, then presented to the ED in the middle of the night.He reported chest pain that developed several hours prior to arrival and was 5/10 in intensity. The pain was located in the mid to left chest and developed after riding his bike. There was associated fatigue when symptoms developed and mild shortness of breath at onset of chest pain however that has since resolved.  The patient states he experienced similar 7/10 chest pain 2 days prior when he had to hurry to catch the bus. He states he experienced shortness of breath and chest pain with exertion and once he sat on the bus his symptoms slowly resolved. He presented on this day because it did not go away.Here is his first ECG (1/10 pain):Smith: sinus rhythm with RBBB and normal ST-T.  No ischemia.An ECG from 4 years prior was the same.The Queen of Hearts interpreted" OMI with Low confidence ".  This surprises me, but the Queen often sees things that I cannot see.  On the other hand, I have also seen quite a few false positive Queen interpretations in the presence of RBBB.The explainability map is here:It seems that part of the diagnosis of OMI is due to T-wave inversion in V4 and V5.  In RBBB, the T-wave should be normally upright, so this is indeed abnormal.Case ContinuedThe first hs troponin I returned at 139 ng/L.Management:The clinical scenario with a troponin of 139 makes...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs