An elderly woman transferred to you for chest pain, shortness of breath, and positive troponin - does she need the cath lab now?

Written by Alex Bracey, with edits by Smith and MeyersA female in her 70s presented to the ED at sign out while working in our acute zone (medium acuity). I picked up the chart and the triage note indicated that the patient was transferred from another hospital, with " EKG changes " and elevated troponin, for cardiology evaluation of NSTEMI. Symptoms were ongoing.Interest now piqued, I looked at the EKG and saw the following:What do you think? Baseline for comparison below.This is nearly pathognomonic! Of what?Baseline on file from outside hospital:This is her first ECG at our hospital:Meyers ECG interpretation: The new ECGs show sinus tachycardia with convex ST segments leading into large T-wave inversions in the anterior and inferior leads. The morphology is consistent with many prior examples of acute right heart strain we have shown on this blog. Also, even if these T-wave inversions had been due to reperfusion of OMI (despite the fact that they are not the right morphology for this), they would usually coincide with significant improvement in the patients symptoms, whereas this patient has ongoing severe shortness of breath during this ECG. The T-wave inversions are also not " too big " for the QRS, meaning out of proportion for reperfusion or acute right heart strain, such as those due to takotsubo cardiomyopathy as seen inthis post.Back to the case:Having recently seen a post on pulmonary embolism (this one), I was immediately concerned that the patient had a...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs