The Interventionalist Refuses Angiography, and even to speak to the Emergency Physician

A recent residency graduate, let ' s call her " The Graduate " or " TG, " texted me these ECGs from somewhere far away across the country, in real time, in the hopes of being able to persuade the interventionalist to take the patient to the cath lab.CaseAn otherwise healthy middle-aged patient presented with chest pain of uncertain duration.Here is the initial ED ECG (I apologize for the poor quality of these images -- they were mobile phone photos of computer screens, texted to me -- but they are good enough!):What do you see?There was a second ECG after the patient had symptom resolution:What do you see?This is what TG and I saw: ST elevation in lead V1 during pain (with a tiny amount of terminal T-wave inversion), then resolution of STE and more prominent T-wave inversion after resolution of pain (ECG 2).  Looks like Wellens ' in V1 only!  This ECG is typical of the rareisolated right ventricular STEMI.There is also somevery minimal inferior STE, with reciprocal STD in aVL, which is gone after reperfusion (ECG 2).  The very narrow-based, peaked T-waves would be an unusual manifestation of MI.There is quite a bit of diffuse T-wave peaking.  Hyperkalemiacan result in ST elevation in V1 and V2, so onemight wonder about hyperkalemia, although such ECGs really look very different from this, especially because the QRS should be prolonged.  In our case here,the K was normal.Here are examples of ST elevation in V1 due to hyperkalemia.Hyperkalemia and ...

Source: Dr. Smith's ECG Blog - January 11, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs