A 60-something year old man with chest pain and a wide QRS

Written by Pendell Meyers, with edits by Steve SmithA man in his 60s with history of CAD s/p PCI, HTN, presented with chest pain which started while doing construction on his house several hours prior to arrival.Here is his ECG on arrival at 2052:What do you think? Should you activate the cath lab?Yes, because there is an acute coronary occlusion causing OMI of the inferior wall. This is evident based on the LBBB with excessively discordant STE in leads II, III, and aVF, with reciprocal findings in I and aVL.But the current guidelines do not use the modified Sgarbossa criteria, but rather theoriginal Sgarbossa criteria. Because the STE in the inferior leads does not meet the 5mm threshold, it is negative by the original Sgarbossa criteria, as there is no concordant STE or STD.The patient was given ASA and NTG drip with improvement but not full resolution of pain.Initial troponin T was undetectable.Troponin T at 2200 was 0.10 ng/dL (elevated).Here is his repeat ECG several hours later at 0022:There has been interval marked improvement of OMI findings, implying the artery has reperfused. Another repeat at 0248:Still no signs of reocclusion.Troponin T at 0306 was 0.80 ng/dL.Troponin T at 0649 was 1.60 ng/dL.The patient was admitted to cardiology for urgent cath.1629: Cath shows an acute thrombotic ostial RCA in-stent restenosis culprit, 95% stenosed at the time of cath with TIMI 3 flow. Stent placed with good angiographic result. He also had a 70% chronic mid LAD stenosis, ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs