Chest pain, Ventricular Paced Rhythm, and a Completely Normal Angiogram 3 Months Prior.

One of our graduates, Rochelle Zarzar, who is now an education fellow, sent me this from one of the hospitals she works at now:An elderly woman presented with chest pain.  She had been nauseous the night before and did not feel well, then awoke 2 hours prior with chest pain.She had had a completely normal angiogram 3 months prior.Here is that angiogram report:The left main coronary artery is normal.Left anterior descending is a type 3 vessel and is normal.Left circumflex is nondominant and normal.The right coronary artery is dominant and normal.The nurses immediately recorded an ECG.  This was 2 hours after the onset of CP:What do you think?Analysis:There is a ventricular paced rhythm.  It is unusual in that the QRS is mostly positive in leads V1 and V2.  This suggests that it is a biventricular pacer that is timed to pace both ventricles simultaneously (only one spike).  There is concordant ST depression of at least 1 mm in V3 (+ Sgarbossa), andproportionally excessively discordant ST elevation in I and aVL, with reciprocal concordant ST depression in III and aVF (+ Smith modified Sgarbossa).  So this is clearly an acute coronary occlusion (Occlusion MI, or OMI).Remember: all you need for the diagnosis of OMI is for the Smith Modified Sgarbossa to be (+) injust one lead.  Here it is positive in 3 leads.They later found the old ECG:Paced, with (as expected) all appropriately discordant ST segmentsThe change confirms the ECG di...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs