Epigastric pain radiating to the chest for 18 hours. ECG makes the Dx. Troponin makes the Dx. CT makes the Dx!

I was shown this ECG with no other information:What do you think?Hint: try to see through the artifact!I answered immediately: " High lateral MI with posterior MI. OMI. " (Occlusion Myocardial Infarction)I asked, " Did the patient present with chest pain? "Here is the history:" A middle-aged male complained of about 18 hours of epigastric pain that radiated to the chest.  He also had an apparently new facial droop of equal duration.  A stroke code was called, NIH stroke scale was only 1, and attention was turned to the chest pain. "  BP was 148/83.How did I make this ECG diagnosis?There is subtle STE in aVL with reciprocal STD in II, III, aVF,and STD in V3 and V4.While there are ECGs that have STE in aVL with reciprocal STD in II, III, aVF in the absence of OMI, they do not also have STD in right precordial leads.  Furthermore, the morphology here is perfect for OMI.(See the bottom of the post for 3 ECGs from this week with STE aVL and STD III, for which my answer was " no ischemia. " )They performed a point of care cardiac ultrasound (parasternal short axis):What do you think?Notice the upper right (septum) contracts much more vigorously than the lower right and right (lateral wall)The physician did not appreciate this because he was thinking about the patient ' s pain combined with the facial droop, and so he appropriately obtained a chest CT aortogram to look for aortic dissection.  It did not show dissection, but did show the f...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs