ST segment concavity is just one small piece of the puzzle that is pattern recognition

Written by Pendell MeyersHere are two striking examples from a single shift highlighting the fallibility of the standard " smiley face " or upwardly concave ST segment morphology " rule " .Case 1.Obvious STEMI and OMI with massive STE in the inferior and lateral leads, even extending back into V3. All STE has concave upward (smiley face) morphology. V2 shows STD indicating posterior involvement. V1 may be in a tug-of-war between STD from posterior involvement and STE from possible RV involvement. Reciprocal STD in I and aVL. Sinus bradycardia with first degree heart block present, clearly high risk for worsening bradycardia and/or heart blocks.I received this ECG via telemetry from an ambulance far from our hospital. There was another cath center closer than our institution, so we agreed they should go there and advised they activate their cath lab immediately. Before our conversation was finished, the patient went into VF arrest and they hung up. I was unable to get back in touch with them for the outcome.Case 2.Hyperacute T-waves in V2-V6, I, and aVL. STEMI criteria met by the STE in V6, I, and aVL. Reciprocal STD in III and aVF. V5 has very diminished voltage and poor quality, suggesting some combination of lead misplacement and/or physical object between it and the patient (hair, defibrillation pad, medical cables, clothing, etc.).I received this also by telemetry, and again we agreed with their plan of the nearest cath center and activated their cath ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs