Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

This was written by Sam Ghali (@EM_RESUS), with a few edits by me. 52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. She is somewhat hypertensive, but her vital signs are otherwise normal. Here is her 12-Lead ECG:  There’s a sinus rhythm at around 70 bpm. There are Q-waves in the inferior leads (II, III, & AVF) with ST-Elevations. These elevations meet STEMI criteria (≥1mm in 2 contiguous leads). However, old MI w/aneurysm morphology (persistent ST-Elevation) can look just like this. Looking closer, we see clear ST depression in the lateral limb leads, I and AVL. While this may be change that is reciprocal to an Acute/Subacute Inferior STEMI, the problem is that LV aneurysm may also manifest with this reciprocal change. [This is further complicated here by the fact that this patient has LVH & strain pattern (R wave in AVL > 11mm) which can also account for these changes]Is this a Acute/Subacute STEMI or an Old MI with persistent STE/ “Aneurysm Morphology”? What are some clues to help us differentiate between the two in this scenario?1.  Ischemic Hyperacute T waves (Tall, round, symmetric, vs the “pointy” peaked-T’s of HyperK), are often a clue to ischemia. In STEMI, they are generally upright and large in proportion to the QRS. The T-waves here are not upright or particularly large. So this argues against acute STEMI. However, we must also...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs