A young man with sudden chest pain

A 30-something with history of 2 pack per day smoking complained of sudden left arm and chest pain while working construction. It was very distressing for him. He presented by private transportation, stating that his pain was decreasing.At triage, he had this ECG recorded:The computer read that there is incomplete right bundle branch block.QRS duration 102 ms.What do you think?No significant abnormalities were seen in triage, and the patient had to wait 2 hours. By the time he was roomed, his pain was gone.A second ECG was recorded, pain free:If you didn ' t see anything wrong with the first one, maybe you can see it now by comparison with this one.His first troponin I, drawn 4 hours after arrival, was 1.6 ng/mL.Analysis:--There is subtle ST Elevation in inferior leads II, III, aVF, with reciprocal ST depression in aVL. This is diagnostic of inferior injury. The fact that it resolved with resolution of chest pain simply verifies this.--There is also a decrease in the size of the lateral precordial T-waves.--Notice that the ST elevation on the first ECG does NOT meet STEMI criteria. There is not 1 mm of STE in any lead.--But that ECG is diagnostic of injury.The patient was started on heparin.Shortly thereafter, he had a run of ventricular tachycardia. Therefore he was taken urgently to the cath lab. [Patients with ACS who have persistent refractory pain, hemodynamic or electrical instability, or pulmonary edema, should go emergently to the ca...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs