A middle aged man with ST depression and a narrow window of opportunity

Written by Pendell MeyersI received a text at 18:13 of an ECG taken several minutes prior, with no clinical information and only the question " De Winters? "Here is the ECG:What would you tell the treating team???I responded at 18:14 PM:" I think it's posterior STEMI (OMI) instead of de Winter. Cath lab immediately is indicated. "I clarified further:" De Winter would need hyperacute T waves (not present here), and would indicate acute occlusion of the territory in the affected leads; so if there was de Winter in anterior leads, that would mean the anterior wall is the one involved. Here we have isolated posterior STD, with no hyperacute T wave, so that's OMI of the posterior wall. Posterior wall may have hyperacute T's if posterior ECG is recorded. "Let's go back in time and see the full case play out.A middle aged man with HTN, DM, and CAD (with two prior stents) presented for chest pain, shortness of breath, and palpitations that started several hours ago (2-3 hours) while walking his dog. He was triaged at 17:34, had normal vital signs except tachycardia, was not in cardiogenic shock, and had this ECG obtained:There is atrial fibrillation with rapid ventricular response at about 150bpm. There is massive ST depression in leads V2-V3, with smaller amounts of STD in V4-5, I, II, III, and aVF, with obligatory reciprocal STE in aVR. The J point in V6 is isoelectric, which would be unusual in the case of widespread supply/demand mismatch ischemia be...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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