A 20-something male with acute chest pain

I was texted this ECG with the words " sudden onset CP in a 20-something " :What do you think?This was my response:" This is abnormal in lateral leads. It probably is a normal variant but I would get a stat echo.It is out of the bounds of the usual with normal variant because the ST Elevation is so focal to the lateral wall. Most normal variant has as much inferior STE as lateral (and of course without ST depression in aVL).  This is myocarditis versus myocardial infarction. He should get an immediate echo.  Problem is, even myocarditis will have a wall motion abnormality. And then the only way to tell rapidly is with an angiogram.  So if there is a wall motion abnormality, go to the Cath Lab.  Diagnosis will still probably be myocarditis. "I didn ' t realize it at the time, but this was the 2nd ECG.Let ' s go back to time zero:There was less ST elevation on this one.Unbeknownst to me, the first troponin I had already returned elevated to 3.0 ng/mL by the time I received the text.Here is more history:The patient had an acute onset of epigastric and chest pain this morning. He was in 9/10 pain that last over an hour and did not improve with repositioning.There was a repeat ECG at 70 minutes (the one texted to me)There is increased STE in V4-V6.Here is the echo report:The estimated left ventricular ejection fraction is 53 %.  Normal left ventricular cavity size.Regional wall motion abnormality-distal septum anterior and apex, po...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs