Chest pain in an Elderly Woman

This case was sent by one of our great FOAM colleagues, Salim Rezaie of REBEL EM!!"A 67 y/o female with PMH of Type 2 DM, HTN, Hyperlipidemia, and Hx of MI x 2, with chronic kidney disease awoke at 2am with left sided chest pain. She arrived at 2:45 AM and had this initial ECG below:"What do you think? Smith response: There is sinus rhythm.  There is No significant ST elevation in any lead.   There are large, symmetric T-waves in I, aVL, V2-V5 diagnostic of proximal LAD occlusion.  There are also down-up T-waves in III and aVF (these are very specific RECIPROCAL findings and clinch the diagnosis.)Salim was very worried about these T-waves and so brought the patient the Medical Resus room and did an immediate bedside echo (not shown) which he read as a lateral wall motion abnormality; then he activated the cath lab.He recorded a second ECG 5 minutes after the first:Now there is obvious high lateral ST elevation, as well as STE in V2, V3, V4, V5.He writes:"Patient was immediately taken to cath lab. Initial Troponin was (I'm not sure if 0.03 is level of detection or 99% reference, and I did not clarify that with Salim)."We obtained that result after the patient was already gone. Subsequent Troponin I values were 53.6 ng/mL and 152.04 ng/mL."  This is a large anterior MI."In my mind this was a circ lesion due to STE elevation in lateral leads, but…."Cath showed:"Prox LAD 70% lesionLarge D1 100% occlusion...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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