A man in his sixties with chest pain at midnight with undetectable troponin

Written by Pendell MeyersA male in his 60s with no known past medical history presented at midnight with chest pain over the past 3 hours. The pain started just after eating, and at first he thought it was " reflux, " however he decided to call 911 after a few hours when it did not improve.Here is his presenting ECG:What do you think?Here are the relevant findings:Slight STE in V12.5 mm STE in V2Slight STD in V4-V6Definite STD in II, III, and aVFHyperacute T-waves in V2, and likely also in aVLThese findings are highly specific for LAD occlusion. We have many cases of this pattern on this blog, involving STE and hyperacute T-waves in V1-V2, with STD in the lateral leads (see below for links). In this case there is also reciprocal STD in inferior leads and hyperacute T-waves in aVL. Side note: Sometimes this pattern includes morphology which some have described as " new tall T-wave in V1, " or sometimes " T-wave in V1 greater than in V6 " which is essentially just a description of a hyperacute T-wave in V1, with the exception that it would be better described as both tall and fat/large/wide/bulky T-waves, not just " tall " . Dr. Smith noted " new tall T-wave in V1 " in 14% of cases of early repolarization vs. 34% of subtle LAD occlusions in the derivation study of the anterior OMI formula. This initial ECG does not have this pattern, however lookout for this pattern in the serial ECGs.Our team recognized that this ECG represents LAD occlusion. But it does not technically m...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs