A Middle-Aged Man with crescendo angina

A middle-aged male with several comorbidities including DM presented with chest pain.  It had been on and off all day, then constant for 2.5 hours.  It was central without radiation, sharp but also tight, and was 9/10.   There was some cough, but no SOB; he reports COPD and has been using his inhalers without improvement. He also reports diaphoresis and tingling of his hands since the worsening of pain at 1700.His BP was 160/90.He was given aspirin and nitro via EMS with good improvement in his chest pain.First ED ECG at 2:40 after chest pain became severe.Sinus rhythm.Slight left axis deviation (mostly negative QRS in II, R-wave aVL; axis about -40)There is a bit of suspicious flattening of the ST segment in inferior leads and a tiny bit of STE in aVL, but it is really non-diagnostic and nearly normal.Precordial leads all have minimal, if any, ST elevationHere was a previous ECG while dehydrated a few months prior:Sinus tachycardia. In this ECG, there is a hint of ST elevation in III, with reciprocal ST depression in aVL.None of this was ischemic, but it does suggest the patient ' s baseline is different from the presentation ECG above.Here I put limb leads one after the other for more close inspection:II,III,aVF,aVL only: Presentation ECGII,III,aVF,aVL only: Previous ECGAt approximately 30 minutes after arrival, the first troponin returned at 0.046 ng/mL (99% URL = 0.030 ng/mL)The patient was put on heparin and Nitroglycerin, but his pain could not ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs