18 hours of intermittent chest pressure

A male in his 60's with no previous cardiac history complained of substernal chest pain intermittently for 18 hours.  It has more recently become constant.  He was diaphoretic.  He called 911 and had this prehospital ECG recorded:I saw this when he arrived, and was worried about the slight ST depression in V2 and the size of the T-waves in V5 and V6, as well as the minimal terminal T-wave inversion in aVL and a bit of ST depression there.We recorded this immediately:The same findings are here, without any evolution.BP was 140/80.His pain continued and would be relieved from 8/10 to 6/10 with sublingual nitroglycerin.  We gave aspirin and clopidogrel for high suspicion of ACS.Had I looked for it (which, foolishly, I did not), I would have found this previous ECG from 9 months prior:There are definite changes compared to this oneHad I seen this, I would have immediately diagnosed definite ACS and started high dose IV nitroglycerin.As it was, we did give sublingual NTG, and sent a troponin and, while the pain continued, recorded this ECG 42 minutes later:The T-waves in V5 and V6 have less amplitude.  This caught my eye. Not having seen the old one yet, and seeing no diagnostic evolution, I just kept a high index of suspicion.  But I was pretty sure that, with the duration of pain, that if this chest discomfort was indeed due to ACS, that the first troponin would be at least slightly elevated.The first troponin then returned at 0.20 ng/mL (norma...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs