IVCD, Saddleback STE in III, with reciprocal STD in aVL: Is it pseudoOMI or OMI? Echo with Speckle Tracking gives the answer.

A 77 y.o. woman with a history of hypertension and congestive heart failure presented for acute onset chest pain and shortness of breath. She stated that she woke up in the morning with a central chest pressure with associated shortness of breath. She had been feeling well the day before.She had no h/o CAD but had a history of " unspecified cardiomyopathy "No old EKGs or angiogram were available.This ECG was texted to me with no information:What do you think?There is ST elevation in inferior leads, with reciprocal ST depression in aVL, so one must strongly suspect acute inferior MI.However, 3 features made me think that it could be a false positive (pseudoOMI):1) There is LVH2) There is an intraventricular conduction defect, with QRS duration of 125 ms3) There is an RSR ' (saddleback) in lead IIIMy response was that the diagnosis of inferior OMI is probable but not certain.I was looking at it on my phone when I gave that opinion; looking at the full size version I am more convinced of OMI than I was at the time.Case continued:The emergency physicians were also not certain.So they did a bedside point of care cardiac ultrasound,Here is the parasternal short axis:The area on the lower left of the image has poor contractilityApical 4-chamberThis shows, to my interpretation, an apical wall motion abnormality, and of the distal septumThis one was done withSpeckle Tracking Strain Echocardiography.The lavender line is associated with the lavender sector where it says " inferior " .Th...
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