Acute chest pain in a patient with cardiomyopathy and a paced rhythm.

A 70-something with h/o cardiomyopathy, ICD, LVH was awoken with sharp chest pain, 8/10, non-radiating.  It worsened through the morning and she was eventually brought to the hospital.An ECG was recorded:What do you think?Here is one from 3 years prior:There is a paced rhythm in all 12 leads.  The new ECG has new ST Elevation that meets the Smith modified Sgarbossa criteria in leads I, aVL, and V2.  (ST elevation at the J-point is at least 25% of the depth of the preceding S-wave).  Meeting the criteria in just one lead is very specific for OMI in paced rhythm.She was given aspirin, ticagrelor, and heparin, and the cath lab was activated.The initial troponin was 0.138 ng/mL.  Previous values were approximately 0.030 ng/mL (chronic myocardial injury from cardiomyopathy).Angiogram results:" No evidence of plaque rupture, coronary occlusion or severe epicardial noted to explain chest pain, anterior ST segment changes in the setting of LBBB and troponin elevation. "" Patent mid-RCA stent and otherwise mild, diffuse CAD. "" Consider cardio-embolism, resolved thrombus with medical therapy or non-cardiac etiology for myocardial injury. "After angiogram:The findings are still present.This suggests that whatever caused this new ST elevation is still present, so it is hard to attribute this to transient thrombosis or lysed embolism.Troponin profile:baseline was about 0.030 ng/mLEcho next day:p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px ' Courie...
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