Chest Pain and Cardiogenic Shock with Profound ST Depression & STE in aVR. Activate the Cath Lab?

A middle-aged woman with known severe coronary disease had onset of substernal chest pain while at dialysis. 911 was called. A prehospital ECG was similar to the first ED ECG, which is shown below. The patient arrived with a systolic blood pressure of 90 mm Hg, too low to administer nitroglycerine. An initial lactate was elevated at 5.5.She was given aspirin, heparin, and ticagrelor.Here is her initial ED 12-lead ECG:There is atrial fibrillation with a rate of approximately 114.There is extreme ST depression in multiple leads and ST elevation in aVR, suggesting left main and/or 3 vessel disease ischemia.There is some STE in V1 and aVL, further suggesting left main involvement.Is this Acute Coronary Syndrome?Do you want to activate the cath lab?What else do you want to know?It is important to note that these findings, if due to atherothrombotic acute coronary syndrome (ACS), are NOT due to occlusion of the left main, as is frequently stated in online postings and in literature. Instead, it is far more commonly due to severe obstruction with continued flow (an open artery). See this post:ST Elevation in Lead aVR, with diffuse ST depression, does not represent left main occlusionThere are many causes of diffuse ST depression, with reciprocal ST elevation in aVR. It is most commonly due to demand ischemia, not due to ACS!  So it pays to do a few minutes of research prior to making any drastic management decisions.First, there was an EC...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs