An intoxicated, agitated, 20-something with chest pain

Here is a one hour lecture on the topic of subtle coronary occlusion, especially on the left anterior descending coronary artery. Case 1:The outcome of this case is at the far bottom.A thin, athletic young African American male presented by private transportation to the ED after use of " ecstasy " and alcohol and other drugs. He complained of severe chest pain and was extremely agitated, so much so that he was throwing chairs in triage. He had an ECG recorded and was brought to a room. Here is the ECG:Figure 1:Sinus rhythm.What do you think?Figure 1 shows marked ST Elevation (STE) at the J-point relative to the PQ junction:1.5 mm in V23.0 - 3.5 mm in V32.0 mm in V4The size of the T-wave relative to the QRS in lead V2 is concerning; it is due to very low QRS voltage.Technically, the STE meets STEMI criteria because there is greater than 2.5 mm STE in V3 and greater than 1 mm in an the adjacent lead V4 (even though V2 does not meet criteria of 2.5 mm).But this is a thin athletic 20-something and since such STE can occur in this population, it is easy to dismiss it. The normal upper limit for ST Elevation in lead V2 (as measured at the J-point, relative to the PQ junction) in males under 30 years is 3.0 mm and 3.5 mm in 20 year old males.How about using the LAD-early repol formula to help differentiate normal variant ST elevation from the ischemic ST elevation of LAD occlusion?The formula comes from this paper:In this complex paper, we compare Subtle LAD...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs