Middle Aged Male with Burning Chest Pain -- Assess the Entire Clinical Scenario

A middle-aged male presented with “burning” mid chest pain, with radiation to bilateral shoulders (pain radiating to both shoulder is very specific for ischemia).  It started about 5 hours prior to arrival.  He obtained little relief from nitro x 3 by EMS.  There was a history of previous MI, with a stent in the 1st Obtuse Marginal.  He had taken his Plavix for 6 months, then discontinued and also stopped taking his antihypertensives and statin.  He continued to smoke about 1.5 pks per day.Here is his ECG:Junctional Bradycardia (this is sinus arrest with junctional escape, and is highly suggestive of ischemia).  There is a pathologic Q-wave in lead III (old? new?).  There is slight ST depression in leads I, II, and V3-V6 (fairly specific for ischemia). Down-Up T-wave in aVL: very specific for ischemia! There are slightly hyperacute T-waves in inferior leads (probable ischemia). These are subtle findings.  No single finding is diagnostic of ischemia but he has a very specific combination of factors:1. typical pain2. h/o coronary disease3. pain radiating to both shoulders4. junctional bradycardia5. Q-waves6. ST depression7. Down-Up T-wave in aVL7. Possible hyperacute T-waves All of these together, but none of them by themselves, diagnose acute MI.One of my former residents diagnosed this as inferior MI and activated the cath lab.  I love it when my residents become better than I at reading ECGs!There...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs