Looking for a wall motion abnormality can lead you astray

A Middle-aged male presented with chest pain of 3 hours duration. He has a history of hyperlipidemia only.  There is pressure to mid-chest, radiating to the right arm, associated with diaphoresis.   He never had this before.  It was not related to eating.  There was no cough or fever, nor trauma.  There was no recent surgery, and no h/o thromboembolism. Exam and BP were normal.Here is the first ECG:  0526There is ST elevation in V1-V4, with concave ST segments.  Is it ischemic, or is it early repol?It does not meet STEMI "criteria," but we know they are insensitiveFirst, look for any reciprocal ST depression and you see it in lead III, plus some subtle STD in II and aVF.There is a bit of ST elevation in I and aVL as well.When there is reciprocal ST depression, it is likely to be LAD occlusion and the LAD occlusion formula may be falsely negative.Indeed, if you do make the calculation, with STE60V3 = 4, QTc was 385, and R-wave amplitude in V4 = 20 results in 20.98, which is quite lowThere was a previous ECG for comparison:This is truly normal, without any significant ST elevationYou can see that the T-wave are now much larger than on the previous ECG.These changes are diagnostic!But the clinicians were not convinced.So they did a bedside echo.  Here are 3 parasternal short axis views: They read the echo as normal, without a wall motion abnormality. Is it normal?Comment: I think I see a clear wall motion abnormality of the anterior wall...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs