STE in aVR and diffuse ST depression: It can be ACS or demand ischemia. If ACS, either posterior STEMI or subendocardial ischemia!

A middle-aged male with a history of 2-vessel coronary bypass called 911 because of the relatively sudden onset of severe SOB.  He had had more mild SOB for the past 2 days.  The medics found him in respiratory distress with coarse breath sounds, a BP of 196/132, oxygen saturations of 90%, and a pulse of 130.  They put him on CPAP for respiratory support.  He denied chest pain.Here is his prehospital ECG:There is diffuse ST depression, with ST elevation in lead aVRThe patient arrived in the ED and was put on Noninvasive ventilation (BiPAP).  Blood Pressure was 200/110.  A nitroglycerin drip was started and this ECG was recorded:Same as prehospitalThe ischemia could be due to supply/demand ischemia from hypoxia, tachycardia, and hypertension, or it could have been initiated by ACS.  The ECG cannot differentiate.   If ACS, it could be diffuse subendocardial ischemia, or posterior STEMI.  Does that matter?Bedside echo showed diffuse B-lines of pulmonary edema.The plan was to completely control the blood pressure and re-assess for ischemia.BP was controlled to 120/70 with very high dose Nitro, and the patient's respiratory distress was improved, and another ECG was recorded:Continued ST depressionNow we have controlled the excessive demand but the ischemia persists: the BP is not elevated, the heart rate is only mildly elevated, there is no more hypoxia, the hemoglobin returned normal, and there is no evidence of valvular dysfunction (...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs