Inferior ST Elevation. BP 250/140.

This 50-something patient with no previous CAD complained of havinng had chest pressure the day prior, but stated she was asymptomatic at the time of the ECG.  Her blood pressure was 250/140.  She was well appearing.  She admitted to long standing untreated hypertension.Sinus rhythm.  Very high voltage in the precordium, meeting criteria for LVH, though without the repolarization abnormalities typically associated. There is ST elevation in inferior leads that is diagnostic of focal injury.  The T-wave is inverted in these leads; this is a strong sign of recent reperfusion of the infarct-related artery.  The T-waves in V2 and V3 are suggestive of anterior injury or reperfusion of the posterior wall.Because the ST segment is elevated and T-wave inverted, it appears as if there was very recent reperfusion.  The first sign of reperfusion is inversion of the T-wave, after which the ST segment resolves.  So I imagined that she had had a recent unrecorded upright T-wave, which then reperfused, resulting in inverted ("reperfusion") T-waves, and that the next ECG would show resolution of the ST segment as long as the artery stayed open.Could this all be due to the blood pressure?  I did not think so.  When high demand, such as hypertension, results in ischemia, it is generally subendocardial, with ST depression.I activated the cath lab.  The interventionalist suspected that this might not be ACS because of absence of pain and the ...
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