Two cases of ST Elevation with Terminal T-wave Inversion - do either, neither, or both need reperfusion?

Written by Pendell Meyers with edits by Steve SmithI was sent these 2 ECGs with no clinical information other than chest pain:Do either or both of these ECGs show ischemic changes? If so, what should you do and why?Let ' s take them one at a time.What would your response be?I responded: " Awesome classic benign T wave inversion! That ' s the patient ' s baseline normal variant. ... But if it were a good story with exertional syncope or something you ' d have to treat it like it could be HOCM, etc. Tell me more. "There is sinus rhythm with very large voltage and associated repolarization abnormalities. In V3-V6 there are classic and dramatic findings of BTWI including small or no S-waves, large R-waves, pronounced J-waves, ST-elevation, and steep dramatic T-wave inversions, all with a short QT interval.Later, I was told this history:The patient was a 17 year old African American male with history of asthma who presented with chest tightness and shortness of breath for 6 hours. He improved almost completely after a duoneb (albuterol and ipratropium). However the clinicians were surprised by his unusual ECG findings. He had no prior ECG on file. He had no family history of cardiac issues or sudden death. Labs were normal, including troponin x2. He is able to play basketball routinely without any issues.In the ED he had a CT angio which was negative for aortic dissection. He was admitted for observation and cardiology consult. He had a normal CT coronary angiogram, as well a...
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