What is the culprit artery? Not what you think.

p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 11.0px Helvetica}An elderly woman who was quite healthy except for some chronic renal insufficiency and hypertension had 3 days of classic angina lasting only 10-15 minutes at a time, but which became more constant on the day of presentation.She called 911. Medics palpated a pulse of 80 and a BP of 140 systolic, and recorded this prehospital ECG (day 1):Atrial Fibrillation at a rate of about 120.Profound ST depression: leads I, II, III, aVF, V3-V6.There is STE in aVR (reciprocal ST elevation, reciprocal to the ST depression)This is classic diffuse subendocardial ischemia.She was given a sublingual nitroglycerin and her BP dropped to 80 systolic.On arrival, she still had chest pressure and this ECG was recorded:Atrial fibrillation with rapid ventricular responseDiffuse ST depression, as with prehospital ECGIs the ischemia a result of atrial fib with RVR, or is atrial fib with RVR just exacerbating ischemia whose source is acute coronary syndrome?The history is highly suggestive of ACS.The patient was given a diltiazem bolus and drip, her pulse slowed, and her chest pain completely resolved. Another ECG was recorded:Atrial Fib with a controlled rateThe ST Depression is mostly resolved with this slower rateThe first troponin was, not surprisingly, elevated at 1.07 ng/mL. The blood pressure was well maintained. The patient was started on heparin and aspirin, and coronary angiography was planned for the next morning ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs