30-something with chest pain, a fragmented QRS, and ST Elevation.

A young man presented with acute chest pain.  He had no cardiac history.  He had no medical history at all.  His vital signs were normal.Here was his first ED ECG:What do you think?Here is an old one, from 2 months prior:What do you think?Here I will show them again, with comment:This is very abnormal.There are deep QS-waves in V1-V3.  QR-waves in V4 and I, aVLThere is a fragmented QRS in V3, which is all but diagnostic of old infarctionThere is ST depression in II, III, aVF.This looks like a very large old MI, butit also looks acute, as the T-waves are tall, too tall to assume this is LV aneurysm (persistent STE after old MI; see this post).If the T/QRS ratio in any of leads V1-V4 is greater than 0.36 (let ' s say 0.33 for both convenience and for better sensitivity), then assume there is an acute component to the MI.Here, in V2, the T/QRS ratio = T/S ratio = 7/15 = 0.48Furthermore, the ST depression in II, III, and aVF strongly suggests acute MI.The previous is here:This one had less STE in V1 and a less tall T-wave in V1.This one did not have ST depression in lead II, III, aVFThese confirm that today the patient is having an acute MI.There was a fragmented QRS in V4, III, and aVF and a Q-wave in V5.  The fragmented QRS on the old ECG doubly confirms old MI.The ECGs suggest new ischemia superimposed on old anterolateral MI.But this patient has no history of MI or anything else!I performed this bedside echo (on...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs